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j-7 




THE 



MEDICAL NEWS 



a Meekly /IfteMcal Journal. 



Edited by 



J. RIDDLE GOFFE, Ph.M., M.D. 



VOLUME LXXV. 



JULY-DECEMBER, 1899. 







NEW YORK : 

LEA BROTHERS & CO. 
1899. 



// 






Entered according to the Act of Congress in the year 1899, by 

LEA BROTHERS & CO., 

In the Office of the Librarian of Congress at Washington. All rights reserved. 



ROONEY & OTTEN PRINTING CO 
NEW YORK 



CONTRIBUTORS 



TO 



VOLUME SEVENTY-FIVE. 



AI,BERT ABRAMS, M.D., of San Francisco, Cal. 
\V. V. ANDERSON. M.D., of Toledo, Ohio. 
CHARLES J. ALDRICH, M.D., of Cleveland, Ohio. 
DOCTOR AUVARD, of Paris, France. 
LEWELLYS F. BARKER, M.D., of Baltimore, Md. 
ROBERT H. BABCOCK, M.D., of Chicago, 111. 
J. C. BALLARD, M.D., of Natchez, Miss. 
HERMANN M. BIGGS. M.D.. of New York. 
J. WESLEY BOVEE. M.D., of Washington, D. C. 
GEORGE EMERSON BREWER, M.D., of New York. 
EARL S. BULLOCK, M.D.. of United States Army. 
DAVID BOVAIRD, Jr., M.D., of New York. 
CARL BECK, yi.li.. of New York. 
S. G. BONNEY, M.D., of Denver, Col. 
VINCENT Y. BOWDITCH, M.D.. of Boston, Mass. 
CLEMENT CLEVELAND, M. D., of New York. 
J. O. COBB, M.D., of Fort Stanton, N. M. 
A. B. COOKE, M.D., of Nashville, Tenn. 
PHILLIPE CALDAS, :\I.D., of Rio Grande de Sul, 

Brazil. 
WILLIAM B. COLEY, M.D., of New York. 
JAMES CARROLL, M.D., of United States Army. 
R. G. CURTIN, M.D., of Philadelphia. 
HENRY C. COE, M.D., of New York. 
HENRY DWIGHT CHAPIN, M.D., of New York. 
CAROLUS M. COBB, M.D., of Lynn, Mass. 
CHARLES L. DANA, M.D.. of New York. 
WILLIAM H. DUKEMAN, M.D., of Los Angeles, Cal. 
JOHN D. DUNHAM, M.D., of Columbus. Ohio. 
E. B. DOOLITTLE, M.D., of Hazelton, Pa. 
FRANK DONALDSON, M.D., of United States Army. 
A. W. DUNNING, M.D., of St. Paul. Minn. 
MAX EINHORN, M.D., of New York. 



G. G. EITEL, M.D., of Minneapolis, Minn. 
FRANK H. EDSALL, M.D., of Madison, Wis. 

E. MILTON FOOTE, M.D., of New York. 

F. C. FLOECKINGER, M.D., of La Grange, Tex. 
LAWRENCE F. FLICK, M.D., of Philadelphia. 
SAMUEL A. FISK, M.D., of Denver, Col. 

G. HEUSTIS FONDE, M.D., of Mobile, Ala. 
CHARLES E. FAIRMAN, M.D., of LyndonviUe, N. Y. 
J. HENRY FRUITNIGHT, M.D.. of New York. 
GEORGE G. GROFF. M.D., of San Juan, Puerto 

Rico. 

LANDON CARTER GRAY, M.D., of New York. 

J. M. F. GIBBONS, M.D., of Scranton, Pa. 

J. RIDDLE GOFFE. M.D., of New York. 

VIRGIL P. GIBNEY, M.D., of New York. 

JAMES H. GLASS, M.D.. of Utica, N. Y. 

H. G. GEDDINGS, M.D., of United States Marine 
Hospital Service. 

A. C. GETCHELL, M.D., of Worcester. Mass. 

CHARLES FOX GARDINER, M.D.. of Colorado 
I Springs, Col. 

FRANK HARLEY. M.D., of New York. 

HOBART AMORY HARE, M.D., of Philadelphia. 

M. HARTWIG, M.D., of Buffalo, N. Y. 

GEORGE T. ROWLAND, M.D., of Washington, D. C. 

CHARLES A. HELVIE, of Crete, Neb. 

GEORGE C. HOPKINS, M.D., of Brooklyn, N. Y. 
I L. L. HILL, M.D., of Montgomery, Ala. 

ALVIN A. HUBBELl, M.D., of Buffalo, N. Y. 

CHARLES C. HUBBARD, M.D., of Worthville, N. C. 

JOSEPH W. IRWIN, M.D., of Louisville, Ky. 

JACOB R. JOHNS, M.D., of Philadelphia. 
, CHARLES ROSS JACKSON, M.D., of New York. 



EDWARD JACKSON, M.D., of Denver, Col. 
EDWARD G. JANEWAY, M.D., of New York. 
J. A. JAMES, M.D., of Cheraw, S. C. 
T. H. JAMES, M.D., of Cheraw, S. C. 
SMITH ELY JELLIFFE, M.D., of New York. 
NORBURNE B. JENKINS, M.D., of Chicago, 111. 

A. B. JUDSON, M.D., of New York. 
W. W. KEEN, M.JJ., of Philadelphia. 
HERBERT MAXON KING, M.D., of Grand Rapids. 

Mich. 
HOWARD A. KELLY. M.D., of Baltimore, Md. 
RICHARD KALISH, M.D., of New York. 

D. T. LAINE, M.D., of Havana, Cuba. 
CARR LANE. M.D., of St. Louis, Mo. 
GEORGE F. LIBBY, M.D., of Portland, Me. 
JOHN J. LIGGET, M.D., of Ladiesburg. Md. 

E. B. MONTGOMERY, M. D., of Quincy, Ills. 
JOHN C. MUNRO, M.D.. of Boston, Mass. 
RICHARD K. MACALESTER, M. D., of Glenwood 

Springs, Col. 
W. A. McFARLANE, M.D., of Springville, N. Y. 

B. E. McKENZIE, M.D., of Toronto, Canada. 

H. STUART McLean, M.D., of Richmond, Va. 
CHARLES McBURNEY, M.D., of New York. 
RUDOLF MATAS, M.D., of New Orleans, La. 
ROBERT NEWMAN, M.D., of New York. 
JOHN B. NICHOLS, M.D., of Washington, D. C. 
FREDERICK G. NOVY, M.D., of Ann Arbor, Mich, 
WILLIAM OSLER, M.D., of Baltimore, Md. 
CHARLES O'DONOVAN, M.D., of Baltimore, Md. 
ANGENETTE PARRY, M.D., of New York. 
I. B. PERKINS, M.D., of Denver, Col. 
WILLIAM H. PARK, M.D., of New York. 
CHARLES A. POWERS, M.D., of Denver, Col. 



WILLIAM H. POOLE, M.D., of Detroit, Mich. 

JOHN R. ROSE, M.D., of Eastman, Ga. 

J. MORRISON RAY, M.D., of Louisville, Ky. 

WALTER REED, M.D., of United States Army. 

A. RAVOGLI, M.D., of Cincinnati, Ohio. 

DUDLEY S. REYNOLDS, M.D., of Louisville, Ky. 

EDWARD REYNOLDS, M.D., of Boston, Mass. 

DUNBAR ROY, M.D., of Atlanta, Ga. 

ROBERT SATTLER, M.D., of Cincinnati, Ohio. 

NICHOLAS SENN, M.D., of Chicago. 

A. ALEXANDER SMITH, M.D., of New York. 

ANDREW H. SMITH, M.D., of New York. 

J. COPLIN STINSON, M.D., of San Francisco, Cal. 

THOMAS S. SOUTHWORTH, M.D., of New York. 

W. F. SMITH, M.D., of San Juan, Puerto Rico. 

W. SCHEPPEGRELL, M.D., of New Orleans, La. 

G. SANARELLI, M.D., of Bologna, Italy. 

FRANKLIN B. STEPHENSON, M.D., Surgeon 
United States Navy. 

GEORGE M. STERNBERG, M.D., of Washington, 
D. C. 

E. STUVER, M.D., of Fort Collins, Cal. 

T. E. TAYLOR, M.D., of Denver, Col. 

V/ ALTER TRUSLOW, M.D., of Brooklyn, N. Y. 

JAMES S. TURNER, M.D., of High Point, S. C. 

FELIX VITALE, M.D., of CoytesviUe, N. J. 

J. B. WALKER, M.D., of Philadelphia. 

JAMES J WALSH, M.D., of New York. 

EUGENE WASDIN, M.D., of United States Marine 
Hospital Service. 

WILLIAM H. WATHEN, M.D.. of Louisville, Ky. 

GERALD B. WEBB, M.D., of Colorado Springs, Col. 

FRANCIS H. WILLIAMS, M.D., of Boston, Mass. 

ROYAL WHITMAN, M.D., of New York. 

JOHN A. WYETH, M.D.. of New York. 



THE MEDICAL NEWS 

A WEEKLY JOURNAL OF MEDICAL SCIENCE. 



Vol. LXXV. 



New York, Saturday, July i, 1899. 



No. 



I. 



ORIGINAL ARTICLES. 



A COLLEC Tl VE IN V ES TIG ATIO N OF YELLOW 
FEV EH IN THE I S LAN D F C U B A . 

By D. T. LAINE, M.D., 

MAJOR AND BRIGADE SURGEON, U. S. V., HEADQUARTERS, DIVISION 
OF CUBA, HAVANA. 

In order to take advantage of the experience of 
Havana physicians on the subject of yellow fever, a 
set of ten questions was drawn up in this office and 
sent to the leading practitioners of the city. It is 
owing to the great kindness and courtesy of 
Drs. Santos Fernandez and Tomas Coronado, to 
whom are due sincere thanks, that so many replies 
were received. It will be observed that the ques- 
tions were confined to points of practical interest. 
Thirty-five answers were received from physicians 
living in Havana, and two from Alatanzas. All 
these were sent by men with large practices who live 
in the foci of infection of yellow fever and with suf- 
ficient experience in the treatment of this disease to 
give their personal opinions considerable weight. 

We shall begin by analyzing in figures the opinions 
given, so that a reasonable criticism of the same can 
be found and we can come to a practical conclusion, 
if possible. This work was undertaken and accom- 
plished by said physicians from a sense of courtesy 
and gratitude to Americans, in view of the special 
pains taken by them to study and modify the endem- 
icity of this disease in Cuba, where it has wrought 
so much harm to its industries and inhabitants. 
Even the children, although natives, are none the 
less victims during their early age to the terrible 
scourge, which stands to-day as a barrier to im- 
migration, for which so great a necessity exists in 
the island, from the mortality caused by war and 
from 400 years of criminal neglect of all sanitation. 

I. What is, from your observation, the earliest 
period at which it is possible to make an accurate dif- 
ferential diagnosis of yellow fever, and on 7vhat do you 
base the diagnosis? 

Three physicians claim that it is impossible to say 
precisely at what time the diagnosis can be made; 
seventeen claim that it can be made between the 
third and fourth days; fifteen between the first and 
third days. The diagnosis is based by the great 
majority on the symptoms which are common to 
yellow fever and which are present after the second 
day. Many draw attention to one or various symp- 



toms; others give preference to the combination of 
symptoms if they are present in an individual who 
has recently arrived in the country, or to a native 
child who finds itself under the same conditions as a 
stranger. 

The presence of mucine, the investigation of 
which has not been fully carried out, and albumin in 
the urine, which is apt to appear at the end of the second 
day, the characteristic remission which separates the 
first from the second period and which is noticeable 
between the second and fourth days of the disease, 
the icterus which appears on the third day, and the 
hemorrhages are the principal symptoms which carry 
conviction to the mind of the experienced practi- 
tioner as to the existence of yellow fever. 

2! What do you consider the most pathognomonic 
symptoms of yello^v fever 1 

Seventeen physicians are of the opinion that pa- 
thognomonic symptoms do not exist; eighteen ac- 
cept not one symptom alone, but a number of them 
together as constituting pathognomism. The major- 
ity believe that the remission from the first period 
followed by the sudden elevation of temperature of 
the second period, in conjunction with albuminuria, 
icterus, and hemorrhages are the most typical symp- 
toms of the disease. The physicians who accept a 
group of symptoms as constituting pathognomism 
express themselves as follows: 

Remission from the first to the second period, al- 
buminuria, icterus, hemorrhages; some add to the 
above black vomit and bloody evacuations (which 
should be put under the head of hemorrhagic symp- 
toms), cephalalgia, rachialgia, congestion of the con- 
junctivae, congestion of the face, which are nothing 
more than the phenomena which are proper to all 
infectious and acute febrile diseases, and which, 
although present in yellow fever are also common 
to many febrile conditions, and cannot be accepted 
as characteristic symptoms of the disease. The fall- 
ing of the pulse, even if frequently observed, does 
not constitute, per se, a characteristic symptom ot 
yellow fever, and it is more than likely dependent 
on one of its epiphenomena, biliary disturbances, 
which usually present themselves during the course 
of the fever, when the diagnosis has no longer the 
same relative value. 

J. Given a case of chronic malarial fever, in 
which death occurs from an invasion of yellotv fever, 
zvhat will be the post-mortem appearance 1 



YELLOW FEVER IN CUBA. 



[Medical News 



Twenty physicians express the opinion that the 
lesions of both diseases will be found: fifteen have 
never observed combinations of these two diseases 
and therefore can express no opinion. During the 
war and in the military hospitals it was not unusual 
to meet with soldiers sufiering from yellow fever who 
came from the interior of the island suffering- from 
acute malaria. In those rare cases in which a care- 
ful study of the disease was made, frequently both in- 
fections could be traced without one being able to 
positively state the distinctive features of either one. 

4. Published statistics show a reduction in the mortal- 
ity of yellow fever by the use of the Sternberg treatment. 
Why is it not more generally used? 

Eighteen physicians claim that they do not use it 
because the}' have obtained the same results with 
other treatment; eight claim that the bichlorid of 
mercury is a source of danger; seven physicians ex- 
press no opinion because they have not used it; two 
have used it and continue to do so. 

It is an indisputable fact that since the work of 
Dr. Sternberg was published, the majority of the 
doctors in this island use the alkaline treatment, 
adding other drugs to it for which they have some 
personal predilection. A great many do not use the 
bichlorid, having an exaggerated fear of producing 
mercurialization, undoubtedly a troublesome compli- 
cation, especially in those attacked with yellow fever. 

5. What is your treatment of yellow fever ? 

Fifteen physicians use laxatives, disinfectants, al- 
kalies and tonics; eight use the classic symptomatic 
medication; seven, absolute diet and light laxatives; 
two,eliminativemedication,tonics and hydrotherapy ; 
one, alkaline medication with bichlorid of mercury. 

The great majority of opinions expressed in an- 
swer to this question, the most important of all, show 
the vacillation of the clinicians when dealing with 
an acute infection whose pathogenesis is unknown. 
Every physician is filled with enthusiasm when he 
obtains favorable results with a special plan of medi- 
cation in this disease, but his disappointment has no 
limits when a new case in the same epidemic oranother 
presents itself with possibly more benign symptoms 
and the patient succumbs when treated with the 
same medication which gave him such favorable re- 
sults in the first case. On this account we see prac- 
titioners using all medication that is suggested for 
yellow fever and later on discarding them as they 
acquire the conviction of their inefficacy. As long as 
we have not a more complete knowledge of its patho- 
genesis we cannot hope for a rational or certain treat- 
ment. Those which are proposed will never be more 
than mere attempts to aid the patient in his defense 
against the germs and the unknown toxins which 
are destroying him. Statistics have shown until now 



the futility of all forms of curative treatments pro- 
posed for this disease. It is proper to know 
them all but to hope also that a new study, possibly 
that instituted by Sanarelli, may soon solve this in- 
teresting question. 

J. What is the mortality in your oicn experience? 

Fourteen physicians claim from 27 to 39 per cent.; 
thirteen give no statistics, and six claim that statis- 
tics are very variable. Yellow-fever statistics have 
no value unless they have been carefully gathered for 
a period of at least ten years. If we notice the great 
diflference which exists, one giving 7 per cent, mor- 
tality and another 80 per cent. , we cannot help but 
come to the following conclusions: Either these 
statistics, which represent such extreme limits, have 
been made from a limited number of patients in two 
distinct epidemics or else very benign or malignant 
groups of cases have been included in them. 

The statistics given by the fourteen physicians give 
a mean average of 23 per cent., which is more in 
keeping with the mortality of the severe forms of 
infectious fevers. There is as great diversity of 
opinions in the rate of mortality given as in the 
treatment. 

Now that the season approaches when there will be 
a recurrence of yellow fever and when, untortunately, 
so many non-acclimated strangers will succumb, 
I should propose as an humanitarian means and as 
an important question for our country, that the sani- 
tary officers place under the care of those physicians 
who claim a mortality of 7 or 8 per cent, two wards 
for the care of those cases. If such a reduction of 
mortality could be obtained yellow fever would lose 
much of its terrors. 

7. What is your opinion of the febre de borrasl 
In 7C'hat does it differ from yellow fever ? 

Twenty phj'sicians claim that it is the same as 
yellow fever; seven that it is a malarial fever; three 
have never met with it, and two declare that it is a 
symptom of various diseases. 

The difference of opinion which is apparent in 
twelve of the physicians is proof that they are not 
yet fully convinced and are not willing to go against 
tradition, as not one of them gives conclusive proofs 
to show the nature of the so-called fiebre de 
borras, whose only true difference from true vel- 
low fever is the fact that it appears in the natives. 

The notable works of Dr. John Guiteras, late Pro- 
fessor of Pathology in the University of Pennsyl- 
vania, on the epidemology of yellow fever, and those 
of Dr. Mudan of Matanzas, and others which have 
been made here in Havana during the past three 
years, show experimentally that "fiebre de borras" 
is without question yellow fever. 

We shall only bring forward one argument. If 



JULV I, 1899] 



YELLOW FEVER IN CUBA. 



fiebre de borras was by nature paludic, why is it not 
observed in Europe or in any other country where 
malaria exists? Is it reasonable to suppose that this 
is but a rare privilege conceded to Cuba and other 
foci of yellow fever to have this special form of 
malaria? 

It is only necessary' to carefully observe a few cases 
of fiebre de borras for the most exacting clinician to 
become convinced of its yellow- fever origin. The 
majority of the physicians concede the identity of this 
fever with yellow fever. 

8. What do you understand by acclimatization fever? 

Twenty-three physicians affirm that it is a mild 
form of yellow fever. Ten do not know what accli- 
matization fever is; two refuse to believe it yellow 
fever. 

Physicians in Cuba who have studied the fevers of 
the island have not without good reason given the 
name of acclimatization fever to that fever, different 
from other well-known forms, and which always 
makes its appearance in times of yellow-fever epi- 
demics. Acclimatization fever is the mildest form 
of yellow fever. If its similarity to catarrhal fevers 
or to simple fevers caused by gastric disturbances or 
to others of simple nature is held up as proof of its 
not being a form of yellow fever, no importance 
should be attached to the fact. Learned clinicians 
of repute affirm that the so-called acclimatization 
fever confers immunity to a later and complete at- 
tack of yellow fever. This fact alone confirms what 
a respectable majority of the physicians interrogated 
recognize. 

g. What do \ou consider the most dangerous part 
of the city of Havana, in relation to yelhnc fever 1 

Twenty-three physicians are of the opinion that 
the shores of the bay and the districts in the vicinity 
of the wharves constitute the most infected parts: 
seven, that these are to be found in the Militarj' 
Hospitals, and buildings contaminated by having 
sheltered previous cases. Six state that the entire 
city of Havana is a permanent focus of contagion. 

The whole thirty-five replies confirm the result of 
observations e-xtending over a long period of time. 
The majority believe that the shores of the bay and 
districts adjoining the wharves are the most danger- 
ous. In truth, in these places contagion is more 
active for two powerful reasons that tend to bring it 
about: First, the continuous crowding of foreigners, 
it being the commercial part and more densely pop- 
ulated by newly arrived Peninsular Spaniards, who 
through long-established habit come to live in the 
warehouses and establishments of their relatives and 
friends. These newly arrived immigrants constitute 
the most favorable means of cultivation of germs 
that this filthy and badly ventilated part of the town 



maintains in a latent state. Second, the proximity 
of the fortresses, barracks and arsenal that forced the 
Spanish soldiers to remain in their vicinity rather 
than in other parts of the cit)', and furthermore, the 
sending yearly of new Spanish soldiers who have 
always been in Cuba the sustainers of yellow fever 
and the propagators of its epidemics, from the fact 
of its contagion being denied (or not believed in) 
and there never having been measures of isolation 
and disinfection adopted. The fact of several offi- 
cers dying successively in a building or quarters in 
the barracks of La Fuerza and other places has been 
constantly repeated up to the month of December, 
1898, without it occurring to any one to scientifically 
disinfect those quarters after the deaths occurred and 
much less to isolate the sick. Hotels and boarding- 
houses of these districts, with Spanish officers as in- 
mates, were so many more centers of contagion. 
To the Military Hospitals and infected buildings 
there must be added the Casas de Salud, (private 
infirmaries) of this capital, which, although their 
owners \.xy to hide it, give and have always given 
a terrible contingent of yellow-fever cases. In these 
houses isolation is a myth; in the room of a yellow- 
fever patient there enter at all hours, and retire with- 
out disinfecting themselves, friends and acquaintances 
who unconsciously disseminate through the whole 
city the contagion of the yellow epidemic. 

10. What precautions luould you recommend for 
unaccliinaied people! 

Thirteen physicians recommend observance of the 
general laws of health; nine, the running away from 
the contagion; seven, living beyond the foci of yel- 
low-fever infection; three, the return of foreigners 
to their native countries. Two state that it is not 
possible to suggest a precaution. One recommends 
preventive inoculations. Here we come in contact 
with the difficulties arising from lack of knowledge. 
If we do not know the pathogenesis of the disease, 
how can we adopt precautionary or preventive meas- 
ures? All the measures recommended are good, but 
they are without any practical basis. What does the 
rigorous observance of health-rules and even the 
flight from contagion amount to, of a non-vaccin- 
ated person in the midst of an epidemic of smallpox? 
The same happens with yellow fever, the specific 
germ of which, unfortunately, has not been sufB- 
ciently experimented with to warrant the certainty 
of its identification. 

To fly from the contagion and live beyond the 
yellow-fever centers, is an impracticable measure 
which many foreigners are debarred from carrying 
into effect. The return of foreigners to their native 
country (which would entail a financial disaster to 
this country) and which three esteemed physicians 



CRURAL THROMBOSIS. 



[Medical News 



recommend, would simply prevent those foreigners, 
so returning, from dying here and nothing else. In 
corroboration, it is well to bear in mind the case of 
the unfortunate American engineer, Waring, who, 
although probably living under the most excellent 
hygienic conditions, could not escape contagion and, 
returning to his native country, fell a victim to the 
yellow fever which he had contracted here. And, 
on the other hand, the children of the island under 
ten years of age, not being immunes through a pre- 
vious attack, would have to be banished therefrom. 

It is not to those in health but to the sick that 
efforts must be directed to prevent contagion of yel- 
low fever, establishing the strictest isolation, the 
same as if smallpox, the plague, dysentery or other 
contagious disease were being treated; to prevent its 
progagation so that the germs may die out through 
lack of material to feed upon. In this manner alone 
will it be possible to banish yellow fever from in- 
fested Havana, and Cuban soil throughout the 
island, brought about by the effect of war. 

Modern medical science may well be proud of its 
preventive treatment of contagious diseases, which 
heretofore decimated whole cities, spreading desola- 
tion, terror, and ruin. Yellow fever belongs to this 
class, and its prevention is not a Titanic work nor 
one to be left for some future time. It belongs by 
right to men of the epoch of Pasteur, aided by some 
legislation that recognizes that public health is the 
most important of all things. 



CRURHL THROMBOSIS FOLLOWING ASEPTIC 

CELIO TOMY.' 

By henry C. COE, M.D., 

OF NEW YORK. 

Am()N(; the later complications of abdominal sec- 
tion for disease of the pelvic organs there is none 
that causes more annoyance to the surgeon and dis- 
appointment to the patient than the one which will be 
briefly discussed in this paper. Occurring, as it 
often does, in simple cases in which a rapid recov- 
ery had been confidently expected, and at the end 
of the first, or beginning of the second week, when 
all anxiety regarding the condition of the patient 
has been dismissed, its appearance is as unexpected 
as it is unwelcome. One whose surgical training 
has rendered him skeptical regarding the develop- 
ment of post-operative thrombosis from general 
causes, at once thinks of local sepsis, his suspicions 
being strengthened by the detection of an induration 
in the broad ligament, or at the site of the stump, 
on the affected side, and he begins to review his 
technic carefully in search of some broken link in 

' Read at the twenty-fourth annual meeting; of the American 
Gynecological Society, held at Philadelphia, May 23, 24, and 25, 
1899. 



the chain. If other sources of infection can be ex- 
cluded he is apt to infer that his catgut was faulty, 
since it is well known that the center of the coarser 
sizes may be imperfectly sterilized and may not 
manifest its dangerous qualities until sufficient time 
has elapsed to allow the aseptic peripheral portion 
to become dissolved. Even though the bacterio- 
logical examination of the suspected piece is nega- 
tive, it is impossible for him to dismiss the notion 
that there is a septic element in the case. Since 
there is, fortunately, no opportunity for post-mortem 
investigation, he is obliged to base his opinion en- 
tirely on clinical evidence, which is mainly negative. 

That there is a general disposition to regard crural 
thrombosis following abdominal section as being 
purely of septic origin, and practically identical 
with the milder grade of puerperal phlegmasia do- 
lens, once so familiar to obstetricians, is shown in 
the brief allusions to this complication in many text- 
books and monographs. Kelly and Greig Smith, 
however, representing the most advanced teaching 
in abdominal surgery, carefully avoid using the word 
sepsis in this connection. The latter, in the last 
edition of his well-known work, devotes only eight 
lines to the subject of " edema of the legs," con- 
cluding with this statement: "Most cases could 
doubtless be explained by some traumatism or com- 
pression of a venous trunk in the pelvis by forceps or 
ligature; a few might arise from pelvic cellulitis or 
angioleucitis." 

This explanation is plausible, but far front con-' 
vincing, since it fails to account for the compara- 
tively rare occurrence of thrombophlebitis after total 
extirpation in bad pus cases,in hysterectomy, in myo- 
mectomy, and especially in puerperal hysterectomy, 
where there is always marked dilatation of the ves- 
sels of the broad ligaments and mass-ligatures and 
clamps are so feely employed. Certainly if trauma- 
tism played an important part, the use of the angio- 
tribe would seem to be especially favorable to the 
development of this condition, which is not the case. 

As this paper is essentially clinical, I shall not bur- 
den you with a consideration of elementary facts 
regarding the nature and causation of thrombosis and 
phlebitis or review the various theories of Virchow, 
Cornil, etal. The subject is quite an old one, and 
reference to the English journals as far back as the 
early fifties shows that puerperal phlegmasia had been 
carefully studied at that time. Opposing papers by 
Lee, MacKenzie, and Tilbury Fox' furnish interest- 
ing reading from a historical, if not from a scien- 
tific, standpoint. Lee and Fox regarded phlegmasia 
as a local, MacKenzie as a constitutional, affection. 

^ British and J^oreign Medico-Chiriirgicat Review^ p. 55,1854; 
Medical Times and Gazette^ vol. ii,p.46, 1862. 



July i, 1899] 



CRURAL THROMBOSIS. 



H. Lee, in an earlier paper,' had already opposed 
the view of extension of a septic clot from the uterus, 
and affirmed his belief that crural phlegmasia was 
the local expression of a blood infection. This 
seems to have been the general opinion at this time, 
as it was reaffirmed by J- Y. Simpson." Vaquez's 
monograph' is a distinct addition to the literature of 
this subject, and contains many suggestive sentences, 
which I would like to quote if time permitted. He 
takes issue with Virchow, agreeing with Widal^ that 
phlegmasia is due to infection, even in the mild cases, 
which are attended with slight chills and moderate 
elevation of temperature. He is somewhat confusing, 
since in another place he refers to "aseptic" phlebitis 
following ligation or other injury to a vein, and 
states that an aseptic thrombus may subsequently 
become infected. The micro-organisms found in the 
thrombus, he says, may be identical with those at 
the original focus of infection, or they may be a dif- 
ferent variety, invading the vein from without by 
way of the vasa vasorum. Thrombosis, he con- 
cludes, is not a simple clotting of blood, but is al- 
ways secondary to phlebitis. It is interesting to 
note that he regards it as a rare complication of 
simple ovariotomy. 

Of all the papers which I have read Wyder's gives 
the most information regarding thrombosis following 
aseptic celiotomy. Hisarticleon ''Embolie der Lun- 
genarterien in der geburtshilflich-gynakologischen 
Praxis"' is based on twelve cases with eight deaths, 
which were carefully investigated post-mortem. Un- 
fortunately no bacteriological examinations were re- 
corded. As the author says, they furnish a startling 
commentary on the unavoidable dangers of abdom- 
inal section. The gynecological cases are so inter- 
esting that I venture to insert briefabstracts of them. 

Case I. — Virgin, aged forty years, with old varicosities 
and edema of both legs. Interstitial fibroid the size of 
the fist. Castration. Operation simple, and afebrile 
convalescence up to the fiftti day, when the patient com- 
plained of sharp pains in the left foot. She expired sud- 
denly on the same night. Autopsy showed partly decol- 
orized thrombus in the left saphenous, extending into the 
femoral. Pelvic veins normal. Emboli m the main 
branches of both pulmonary arteries. 

C.'VSE II. — Virgin, aged forty-four years. Castration 
for fibroid the size of a child's head. Operation simple. 
Convalescence normal until the fourteenth day, when the 
heart action became rapid and irregular, and she died in 
a few minutes. At the autopsy the veins in both stumps 
were thrombotic, and the main branches of the pulmo- 
nary arteries were plugged with fresh emboli. l^Iarked 
dilatation of the left ventricle. 

Case III. — ^"irgin, aged thirty-four years. Supravagi- 
nal amputation of the uterus for multiple fibroids, with 

* British and foreign Medico-Chirurgical Review^ p. iii, 1851. 
' Medical Times and Gazette^ vol. i, pp. 567 and 619, 1859. 

3 Clinique Medicate de la Charite^ 1894. 
« These de Parts, 1S89. 

• Sam. klin Vortrage, No. 146. 



extraperitoneal treatment of the stump, the operation be- 
ing uncomplicated. Afebrile recovery until the eight 
day, when she expired with symptoms of pulmonary as- 
phyxia. The left hypogastric vein contained a thrombus, 
and both pulmonary arteries were plugged. 

Case IV.. — Primipara, aged thirty-eight years. Re- 
moval of the adnexa and ventrofi.xation. No symptoms 
until the eleventh day, when the patient was feeling quite 
well. She was suddenly attacked with dyspnea and 
died. Autopsy unsatisfactory, as the source of the em- 
boli could not be discovered. 

Case V. — Multipara, aged thirty-nine years. Re- 
moval of intraligamentary ovarian cystoma of the left 
side, also the right tube and ovary. No symptoms until 
the tenth day, when the patient complained of feeling 
bad, and died in ten minutes. Numerous thrombi 
were found in the veins on the left side of the pelvis, ex- 
tending into the left hypogastric. Emboli in both pul- 
monaries. 

Case VI. — Explorative section for carcinoma of the 
ovaries and peritoneum. Normal convalescence until 
the seventh day, when sudden death occurred with 
cyanosis. Thrombus (presumably old) in the vena cava 
inferior, with pulmonary emboli. 

Case MI. — Mrgm, aged twenty-seven years, in robust 
health. A'entrofixation after removal of the left tube 
and ovary. Convalescence entirely normal until the sev- 
enth day, when she had an attack of dyspnea, with rapid 
pulse, from which she rallied. Two other attacks oc- 
curred during the night, attended by severe pain under 
the left scapula, the third terminating fatally. The left 
pulmonary artery contained a recent embolus, but its 
origin could not be found. The writer believes that the 
accident was directly due to the operation, and that a 
thrombus must have developed in the veins of the stump, 
which had been completely dislodged, leaving no trace. 

In summarizing Wyder states his belief that throm- 
bosis in both the pelvic and crural veins is not un- 
common after celiotomy, but that the thrombi are 
generally absorbed if they do not become infected. 
They are by no means confined to complicated 
operations, as shown by his cases. In general, pul- 
monary emboli are due to thrombi in the pelvic 
rather than in the crural veins, and give rise to no 
symptoms until they have extended to the vena cava. 
They may be present before operation, hence great 
care should be observed in operating upon patients 
with evidences of venous obstruction, especially if 
the heart action is weak, since even perfect asepsis 
does not guarantee recovery 

Mahler,' in an article on the same subject, reports 
fourteen fatal cases of pulmonary embolism occurring 
in the Dresden clinic between 1884 and 1894, six 
after gynecological operations. In every case brown 
atrophy or fatty degeneration of the heart was also 
found (as in the nine cases reported by Hofl'meier). 
He calls attention to the fact that when a large 
neoplasm is removed the intra-abdominal pressure 
sinks and the pelvic veins become dilated. Three 
varieties of thrombus formation are to be distin- 
guished, ws. , the thrombus may extend from the uterus 

' Arbeilen aus der Koniglichen Frauenklinik in Dresden, Band 
ii, 1895. 



CRURAL THROMBOSIS. 



[Medical News 



or its immediate vicinity into the pelvic veins; it may 
originate in the crural vein and extend upward into 
the iliac; it may form in the dilated veins of the 
broad ligaments, which are flabby, thinwalled, and 
cannot contract, so that the circulation is retarded. 
Moreover, the veins may be compressed by plastic 
exudate. The surface left after the enucleation of a 
fibromyoma is analogous to the placental site. Old 
thrombi may be present at the time of operation. 
Schwanz reports two fatal cases of embolism due to 
the detachment of such thrombi, and Dohrn' one in 
a case of fibroid before operation. (I recall a similar 
case at the Woman's Hospital in the service of Dr. 
Thomas. ) Such thrombi are not infrequently present 
in the veins of the thickened broad ligament in con- 
nection with inflammatory disease of the adnexa or 
twisted pedicles, and extend into the pampiniform 
plexus after operation. After hysterectomy thrombi 
may form in these plexuses and in the uterovaginal 
veins on both sides. The capillary system of the 
broad ligament is such that the collateral circulation 
is established slowly. 

In conclusion Mahler also calls attention to the 
more serious significance of intrapelvic as com- 
pared with crural thrombosis, since in the crural 
veins the thrombi tend to become organized, while 
in the pelvic veins, which are without valves, the 
clot may extend up into the iliacs, whence emboli 
may be carried directly to the lungs. In regard to 
crural thrombosis he adds the caution that the ab- 
sence of edema is no indication that serious trouble 
is not present. 

A recent contribution to the subject of thrombosis 
and embolism by Singer' deals more particularly 
with peculiarities of the pulse-curve, especially in 
fatal cases. Although his conclusions are based on 
observation of the phenomena attending puerperal 
thrombosis, they are applicable to some extent to 
post-operative cases. He distinguishes simple and 
inflammatory thrombi; the latter may be due purely 
to gonococcus infection, as shown by bacteriological 
examination, in which case the condition is not true 
puerperal phlegmasia. Singer evidently does not 
subscribe to the view that all thrombi are of septic 
origin. 

It must be confessed that a careful review of the 
literature has failed to establish the etiology of post- 
operative thrombosis, especially with regard to the 
important question of septic infection. 

For information on this obscure subject I natu- 
rally sought the fountain-head, and addressed a letter 
to Professor AVilliam H. Welch, who, in the kind 
and helpful spirit which always marks his attitude 



* Zeitschi/t fur Geb. u. Gyn.^ Band xi. 

3 Archivjiir GynakohgiCy Band Ivi, p. 218, 



toward his younger brethren, replied at considerable 
length to my queries. I take the liberty of quoting 
several sentences from his letter : 

Femoral thrombosis or phlebitis occurring under the 
conditions which you describe is a very interesting sub- 
ject, but I do not think that the underlymg causation is 
understood. I am familiar with this class of cases, as 
several similar instances have been observed hare, particu- 
larly after gynecological operations, but also after other 
surgical operations on the abdomen, as for the radical 
cure of hernia, and, indeed, after surgical operations in 
general. In most cases there was nothing to raise sus- 
picion of any septic or infective condition before the on- 
set of the thrombosis, and then nothing but the throm- 
bosis. In at least one instance the thrombosis involved 
the veins of an upper extremity. I do not know how 
well founded may be the impression which I have seen 
expressed that this complication is more common now 
than formerly. 

Of late years some writers, particularly of the French 
school (Cornil, Widal, Vaquez), consider practically all 
venous thromboses, including those formerly called ma- 
rantic, as infective, and it is true that bacteria have often 
been detected in these thrombi. Still, there are not a 
few negative results in examining the same class of cases, 
and I think that it is going altogether too far to general- 
ize on the observations thus far collected and to assume 
that all these plugs are due to infection. Some have 
thought that the frequent onset with chills, elevated tem- 
perature, and rapid pulse indicated positive infection ; 
but while, of course, suggestive of such an interpretation, 
I do not think that these symptoms are conclusive upon 
this point. 

We have been examining bacteriologically this winter 
all the thromboses found at autopsy, and while sev- 
eral, perhaps the majority, have contained bacteria, often- 
est streptococci, others have been sterile, so that I am 
not convinced of the infective origin of all such cases as 
you describe. Take the thromboses complicating 
chlorosis; these are often severe, with chills, high tem- 
perature, etc., and still thus far (with one very uncon- 
vincing exception) their bacteriological examination has 
been negative. 

But 1 do not think that we can at present exclude in- 
fection in all these cases as the cause, and if we reject 
this explanation we should be quite at a loss for any other 
explanation. I am, therefore, inclined to the hypothesis 
that your cases and similar ones are due 10 infection, but 
at present this is only a hypothesis, and its foundation is 
mainly the difficulty of assigning any other probable 
cause. What is needed is an anatomical and bacterio- 
logical examination of the thrombi in these cases, and as 
the termination is usually favorable, the opportunities for 
such examinations are necessarily rare. 

This is all very unsatisfactory I know, but the whole 
field is one which needs cultivating before any definite 
conclusions are warranted."' 

The following cases occurred in my practice be- 
tween May, 1898, and May, 1899: 

Case I. — (Private.) Multipara, aged thirty-five years, 
with excellent general health, but with a history of recur- 
rent attacks of peritonitis and constant abdominal pains. 
Diagnosis: Laceration of the pelvic floor, retroflexion 
with adhesions, diseased adnexa. Operation May 19, 

' Dr. Welch's article on thrombosis, in the recently published 
volume of Allbutt's "System of Medicine," contains an interest- 
ing summary of existing views on this subject with copious refer- 
ences. 



July i, 1899] 



CRURAL THROMBOSIS. 



189S. Divulsion and curettement. colpoperineorrhaphy, 
followed by removal of both adne.xa and the adherent 
and diseased appendix, and internal shortening of the 
round ligaments. Adhesions slight, and no raw sur- 
faces left within the pelvis. Separate ligation of the 
ovarian arteries, excision of the tubes, and suture of the 
broad ligaments in the usual manner, so that no stumps 
were left. Catgut used throughout. Convalescence nor- 
mal, the highest temperature being 100.2° F. on the first 
day after operation. The patient began to complain of 
pain along the course of the left femoral vein at the mid- 
dle of the second week. Well-marked induration was 
felt in the usual locality just below the grom, with slight 
edema of the foot and ankle. Pulse below 100, and 
temperature 99.5° to 100° F. No constitutional disturb- 
ance. Pelvic examination negative. Primary union of 
the wound. 

The patient was kept absolutely quiet, but during my 
absence from the city for a day (on the twenty-fourth 
day) she insisted on being transferred to her home, which 
was only a short distance from the hospital, where she 
remained in bed for two weeks longer. Stiffness and 
edema persisted for two or three months, so that she 
was obliged to wear an elastic bandage, but she eventu- 
ally made a perfect recovery, and has since led an active 
life, taking long bicycle rides, etc. 

Case II. — (Private.) Multipara, in good general 
health, aged thirty years. Sterile after six years of mar- 
ried life, suffering from severe dysmenorrhea and per- 
sistent pain in the right ovarian and appendical regions. 
Diagnosis : Anteflexion with stenosis, disease of the right 
ovary and tube, and possibly of the appendix. Opera- 
tion July I. 1898. After divulsion and curettement the 
abdomen was opened and the right ovary and tube were 
removed, with the thickened and adherent appendix. 
Ligation with catgut, no stump being left. Left ovary 
and tube entirely normal. During the night following 
the operation (the weather being intensely hot) her tem- 
perature rose to 103° F., but without acceleration of the 
pulse or indications of local trouble. During the week 
which followed the thermometer was seldom below 90° 
F. in her bedroom, and she suffered greatly from the 
heat in spite of ice-bags and cold sponging. Her tem- 
perature was irregular, ranging from 101° to 102.5°, but 
without any evidence of sepsis, so that no alarm was felt 
with regard to her ultimate recovery. On the fifth day 
she began to complain of pain in the left leg; a day or 
two later tenderness in the left groin on deep pressure was 
noted. By vaginal palpation a small, sensitive induration 
was detected at the base of the left broad ligament. Her 
temperature declined steadily after the first week, and 
soon dropped to 100° F., while there was at no time any 
marked acceleration of the pulse (it was seldom above 
1 00) or constitutional symptoms. 

The thrombophlebitis was quite obstinate, pain per- 
sisting for two weeks, while the edema was well 
marked. The pelvic induration could not be felt after 
the second week. Primary union of wound. She left 
for the country five weeks after the operation, wearing an 
elastic bandage, but did not make a complete recovery 
until fall, when she reported in excellent condition. I 
heard through her physician, six months after the opera- 
tion, that she was entirely relieved of her former pains. 

I have never been able to assign a satisfactory ex- 
planation for the sudden elevation of temperature. 
Insolation was suggested as a possible cause. Fever 
developed too early for local sepsis, and was too 
persistent for ordinary traumatic reaction. The pa- 



tient was exceedingly nervous and restless, but I 
have never admitted "nervousness" as a cause of 
fever after surgical operations. 

Case III. — (Private.) Multipara, aged thirty-two 
years ; general health good. Pressure symptoms, dys- 
menorrhea and menorrhagia, and more or less constant 
pain in the right inguinal region. Diagnosis: Small 
ovarian cyst. Operation November 3, 189S. Curette- 
ment, followed by removal of a cystoma of the left ovary, 
the size of an orange, non-adherent. Right ovary and 
tube normal. Catgut ligatures, and no stump. Ap- 
pendix, the size of the thumb, removed and found to con- 
tain concretions, with marked thickening of its walls. 
Convalescence afebrile until the tenth day, when the pa- 
tient began to complain of pain in the left leg. The 
temperature rose to 100° F., and lluctuated between 
100° and 101.5° F. during the next ten days, the pulse 
seldom exceeding 100. Pain and induration along the 
left crural vein, but at no time was there any edema of 
the foot and ankle, merely a slight increase in the 
measurement at the calf. Vaginal examination negative. 
Constitutional disturbance limited to headache, coated 
tongue, diarrhea, and sleeplessness. Primary union of 
wound. The family physician came to the conclusion 
that the patient had developed a mild case of typhoid, 
which I doubted. The temperature became normal after 
three weeks, and she went home during the fifth, wear- 
ing a bandage. She remained in bed for a fortnight 
longer, and called to see me two months after the opera- 
tion, feeling quite well, with the exception of some stiff- 
ness of the leg, which prevented her from walking more 
than two or three blocks at a time. This soon disap- 
peared, and she has since been in good condition. 

Case IV. — (Hospital.) Virgin, aged forty years, a 
dressmaker, who had always enjoyed good health. She 
had a large ovarian cyst, which had undoubtedly existed 
for eighteen years (!), without giving rise to marked 
i symptoms, until within the past year, when it began 
to grow rapidly. Operation March 4, 1899. Der- 
moid cyst, springing from the left ovary, entirely 
without adhesions, although it filled the abdomen. 
Right ovary and tube normal. Catgut ligatures, 
with suture of the broad ligament in the usual manner. 
Temperature reached 100° F. only once, on the third 
day; pulse never above 90. Toward the end of the sec- 
ond week she began to complain of pain along the course 
of the left femoral vein. Moderate edema of the foot and 
ankle. Vaginal examination negative. No constitu- 
tional disturbance. Primary union of wound. The 
symptoms nipidly subsided, and the patient insisted on 
leaving on the twenty-sixth day against advice. She re- 
mained quiet for two or three weeks, and made a per- 
fect recovery. I saw her on May 15th, when she had 
no remains of the trouble, except slight stiffness in the 
affected limb, which did not interfere with locomotion. 

CaseV. — (Private.) Multipara, aged forty-five years, 
strong and well-nourished. Had suffered for several 
months with menorrhagia, pain in the lower abdomen, 
and pressure symptoms. A fluctuating tumor the size of 
a grape-fruit was felt to the right of and anterior to the 
uterus, the organ being enlarged to three or four times its 
normal size. Diagnosis: Ovarian cyst. 

Operation March 23, 1899. Divulsion and curette- 
ment, a small fibromyxomatous polypus and a quantity 
of fungosities being removed. Non.adherent cystoma 
removed from the right side and a commencing cystoma 
of the left ovary. No evidence of fibroid growths. Cat- 
gut ligatures, and no stumps left. 

Convalescence entirely afebrile until tenth day, when, 



CRURAL THROMBOSIS. 



^Medical News 



after a slight chill, the temperature rose to ioo° F., and 
the patient began to have pain at the origin of the left sa- 
phenous vein. The pain was more severe than in either of 
the previous cases, and was persistent, being only relieved 
by the constant use of an ice-bag (which I have found is 
the best local application in this condition), but the tem- 
perature only once reached 102.5° ^- '" "^he evening, 
dropping to 99° F. in the morning. The pulse at no 
time exceeded 100, the average rate being 80, even 
when the temperature was elevated. Marked indura- 
tion along the saphenous vein, with considerable edema 
of the thigh, but none below the knee. Mild constitu- 
tional disturbance. Vaginal examination showed a dis- 
tinct, painful induration at the site of the left stump, which 
could be traced outward to the pelvic wall. This disap- 
peared in a few days with the use of hot douches (as in 
Case II.), while the crural phlegmasia was at its height. 
Convalescence was tedious, but the patient's general con- 
dition was excellent ; she took plenty of nourishment, slept 
well, and preserved her usual equanimity. The temper- 
ature declined to normal at the end of the fourth week, 
when she was allowed to move to the lounge. As the 
pain returned (without rise of temperature) she was kept 
in bed for another week, and was not able to walk about 
her room until six weeks had elapsed after the operation. 
She went to church a week later, and is now (exactly two 
months after the operation) in excellent condition. 

Just after writing the foregoing my attention was 
called to a sixth case, which seems to belong under 
this category. 

Case VI. — (Private.) Primipara, aged twenty-one 
years, a well-nourished German, whom I saw for the 
first time April 6, 1899. She was delivered at term 
three days before. Labor had proceeded normally 
for twelve hours, when the head was arrested at 
the perineum, the pains becoming inefficient. The at- 
tending physician administered two drams of ergot, soon 
after which the child was suddenly expelled with a vio- 
lent pain ; a half minute later a second contraction 
occurred, completely inverting the uterus. The placenta 
was implanted centrally at the fundus, the cord being un- 
usually short. The doctor peeled it off and attempted to 
replace the uterus, which was impossible on account of 
the firm contraction of the ring. The hemorrhage was 
profuse, the patient collapsed, became pulseless, and was 
only kept alive by saline enemata and hypodermatic stimu- 
lation. Twelve hours later her pulse was 180, and the 
following day it remained at 150, and was quite feeble. 
Forty eight hours after the accident an attempt at reduc- 
tion was made under anesthesia, but she again collapsed, 
so that the manipulation was continued for only a few 
minutes. She was transferred to my service in the Gen- 
eral Memorial Hospital seventy-two hours after the acci- 
dent, having a pulse of 130 and a temperature of 101° F., 
exsanguinated, with unmistakable evidences of sepsis. 
Under light anesthesia the diagnosis of complete inver- 
sion was confirmed, but no attempt was made at reduc- 
tion on account of the necrotic condition of the endome- 
trium and the patient's extreme weakness. Decomposed 
membranes and bits of placenta were removed, douches 
of pure peroxid of hydrogen and saline solution were given 
and the vagina was tamponed. 

During the next two weeks the temperature ranged 
from 99° to 101.6° F., the pulse varying from 90 to 120. 
Douches of peroxid and saturated solution of boric acid 
were used, at first every six hours, later twice daily. The 
patient improved rapidly, her recovery being retarded by 
several ugly abscesses on the arms and legs (a legacy of 
the accoucheur). She sat up on the twenty-third day, and 



menstruated normally two days later without discomfort, 
normal involution having occurred. On the thirty-sec- 
ond day after entering the hospital (the thirty-fifth since 
the accident) she was in a good condition for operation. 

Under anesthesia it was at once evident that reduction 
could not be effected by ordinary manipulation. Although 
the uterus was small (about the size of a Bartlett pear), 
the contraction ring was unusually tight. The abdomen 
was opened, and with the able assistance of Dr. Jarman, 
after half an hour of hard work, the ring was stretched 
with the fingers and a Wathen's dilator (the ends of 
which were guarded with rubber tubing), and we suc- 
ceeded in replacing the inverted organ. The tubes, 
ovaries and broad ligaments were perfectly normal, and 
there was no evidence of any obstruction to the circula- 
tion. As the round ligaments were greatly elongated, it 
was deemed advisable to shorten them by Mann's 
method. No reaction after the operation. Temperature 
on the following day was 99.4° F., and after the fourth 
day 98° to 99° F. , the pulse ranging from 80 to 90. Con- 
valescence entirely normal up to the ninth day, when exam- 
ination of the wound showed primary union. The same 
evening the temperature rose to 100.2° F., the pulse be- 
ing 90, and the patient complained of pain in the left 
groin and inner aspect of the thigh. It appeared later 
that she had felt slight pain on the previous day, but had 
not alluded to it. Examination per vaginam on the follow- 
ing day revealed a tender cord, which could be traced from 
the side of the uterus along the base of the broad liga- 
ment to the pelvic wall, where it was evidently contin- 
uous with an induration at the beginning of the saphenous 
vein. Uterus small, in normal position, and insensitive. 
No vaginal discharge; no edema of the limb. The 
evening temperature was 101° F., the pulse 92. No 
constitutional symptoms. On the eleventh day the tem- 
perature ranged from 100.4° to 102.2°, the pulse being 
112. Pain moderate, and slight edema of the footnoted. 
On the twelfth day temp:frature 100.4' 'o 102' F., pulse 
106 to 112. Treatment: Hot vaginal douches, ice-bag, 
elevation of the limb, strychnin and quinin. Patient 
taking plenty of nourishment and presented no septic 
symptoms. 

On the follovi'ing day her temperature fell to 99° F., 
the pain and edema rapidly disappeared, and she was 
discharged at her urgent request, in the fourth week, 
without any trace of local trouble. The pelvic organs 
were entirely normal. Two weeks later she was in excel- 
lent condition. 

I have few comments to add to these clinical 
notes. A rigid revision of the technic, both by 
my associate, Dr. George W. Jarman, and myself, 
failed to reveal any loophole by which infection 
could have crept in. Dr. Jarman himself assisted 
me in four of the private operations and personally 
attended to the sterilization of the instruments and 
field of operation. The nurse was not allowed to 
touch anything that came in contact with the wound. 
According to our usual custom, after thorough ster- 
ilization of the hands by the method employed at the 
Johns Hopkins Hospital, rubber gloves were worn, 
which were removed immediately before the opera- 
tion, when the hands were again washed in alcohol, 
bichlorid 1 : 1000, and saline solution. Neither of us 
had recently attended a septic case. The catgut, 
prepared by Levens, was regarded as above suspicion, 



JLLV I, 1899] 



CRURAL THROMBOSIS. 



and the tubes were sterilized with the instruments. 
In short, as the cases were important ones, every 
precaution was taken to insure a perfect result. The 
disappointment at the failures was therefore so much 
the keener. 

Certain negative points should be emphasized. 
No foci of infection were discovered during the 
operation. Mass ligatures were not used, no stumps 
were left at the uterine cornua, and no raw surfaces 
remained within the pelvis, yet in three cases 
there was evidently thrombophlebitis of the veins 
in the broad ligament of the affected side, which, 
presumably, was continuous with the process in the 
crural vein. Curiously enough, in Case II. there 
had been no lesion of the tissues on the left side, as 
the tube and ovary were normal. The pelvic in- 
durations disappeared within a week, while the cru- 
ral thrombosis was at its height, leaving absolutely 
no traces, such as often persist for months in the case 
of inflammatory exudates surrounding silk ligatures 
and infected stumps. The patients were all in ex- 
cellent general condition before and after the oper- 
ation, with no evidence of circulatory disturbance, 
so that the theory of marantic thrombosis is unten- 
able. No traces of varicosities of the veins of the 
extremities or of those within the pelvis were noted. 
The bowels were moved daily after the third day in 
each instance. In none was there any disturbance 
of the stomach, or any symptoms causing anxiety 
with regard to the ultimate recovery of the patient. 
Pain in the affected limb was the most marked symp- 
tom, and in all but one case it was sufficient to con- 
stitute a true phlegmasia dolens. Induration was 
present in all, but the edema was moderate, local- 
ized, and transient, leading to the inference that 
either the thrombi were parietal, or that the collat- 
eral circulation was free. Recovery was rapid as 
compared with ordinary cases, even though the mis- 
take was made of allowing the patients to leave their 
beds too soon. In but one instance did a chill occur, 
and in only two was there the acceleration of the pulse, 
on which Singer and others lay much stress. In 
short, the clinical histories throw little or no light 
upon the etiology of the condition. Certainly the 
occurrence of six cases of this character within a 
year in the comparatively limited experience of a 
single operator must be regarded as unusual, if not 
unique. 

It is interesting to note that the appendix was re- 
moved in three cases. .Attention has been called by 
Welch to the fact that crural thrombosis has been 
noted in several instances as a complication of this 
operation. 

In this connection I may be permitted to refer 
briefly to a case of crural thrombosis following trache- 



lorrhaphy — a rare complication after this simple 
operation, considering the number of times that it 
has been performed and the septic infection (some- 
times fatal) which used to attend it in the early pre- 
aseptic days. Why it should be so infrequent I do 
not know, in fact, 1 have never met with any allu- 
sion to it in the voluminous literature of Emmet's 
operation. 

The patient (private) was a delicate subject, aged 
twenty five years, whose only labor had been rather se- 
vere, terminated by forceps. Bilateral laceration of the 
cervix, with fixation of the uterus, due to a large cicatrix 
extending to the base of the left broad ligament; lacera- 
tion of the pelvic floor. Operation January 6, 1898. 
Strict aseptic precautions were observed, as in vaginal 
hysterectomy. Curettement, bilateral denudation of the 
cervix, the cicatrix on the left side being dissected out. 
Chromicized-gut sutures. Hegar's colpoperineorrhaphy, 
with a continuous suture of chromicized gut within the 
vagina and a few external sutures of silkworm gut. Con- 
valescence afebrile, and the patient was kept absolutely 
quiet for two weeks. Toward the end of the second week 
she complained of some stiffness in the left leg, but had 
no rise of temperature above 99.5° F. A well-marked 
thrombophlebitis developed, with considerable pain and 
edema. There was tenderness on palpation in the left 
lateral fornix, but no induration could be left. Primary 
union of perineal and vaginal wounds. The patient suf- 
fered from pain and edema for several weeks after the 
operation, and could not walk without a bandage. Ex- 
amination of the cervix at the end of a month showed ex- 
cellent union, and nothing abnormal could be detected in 
the pelvis. It was at least six months before she experi- 
enced the benefit of the operation, and her example 
naturally deterred some of her friends from running the 
risk of a similar experience at my hands. 

In the absence of any evidence of sepsis, and con- 
sidering the anemic condition of the patient, I was 
inclined to believe that this was possibly a case of 
so-called anemic thrombosis, with which the opera- 
tion had nothing directly to do. This view, how- 
ever, is open to criticism. 

The question of most practical interest in connec- 
tion with this subject is that of prophylaxis. Is it 
possible to foresee and to prevent thrombosis after 
celiotomy? Judging from the cases which I have 
reported, we are not yet in a position to give an af- 
firmative reply. Wyder and Mahler advise not to 
operate upon patients with weak hearts, varicosities, 
and edema of the lower limbs. But all surgeons 
operate under these conditions, yet the num- 
ber of cases of thrombosis and embolism are 
insignificant considering the number of opera- 
tions. Wyder' s inference that the frequency of 
this complication must increase with the constant 
increase in surgical activity is hardly borne out by 
the facts. Certainly the mortality after celiotomy 
in the foremost foreign and American clinics has 
steadily decreased with the perfection of modern 
aseptic technic. Improved methods of operating 



CRURAL THROMBOSIS. 



[Medical News 



and greater experience and manual dexterity have 
reduced the actual period of anesthesia, and with it 
the number of deaths from shock, hemorrhage, and 
visceral complications. 

Sepsis is, and always will be, the one enemy which 
we have to fear. When we have succeeded in ban- 
ishing it, at least from without, will thrombo- 
phlebitis be also eliminated in cases which were 
aseptic before operation? 

The diagnosis of thrombosis confined to the pelvic 
veins, as shown by Wyder's cases, is practically im- 
possible; but when combined with the crural variety 
(as in three of my own cases) it may be inferred 
from the presence of an induration extending along 
the broad ligament of the affected side. The recog- 
nition of crural phlegmasia after it is fully developed 
is so easy that even a tyro would not overlook it; 
but it has been affirmed that an expert should recog- 
nize the latent symptoms which appear in what 
Vaquez calls the "pre- obliterating" stage.' Singer/ 
who has devoted considerable attention to a study 
of the pulse, claims that it is always more rapid than 
usual from the outset (that is, after the disturbance 
attending the operation should have subsided), and 
that after the seventh day the curve rises sharply, 
reaches its acme on the ninth daj', when the local 
signs of obstruction appear,there being a direct rela- 
tion between the pulse and the gradual development of 
thrombosis, with the consequent increased resistance 
to the circulation. In a t)'pical case the curve rises 
rapidly, while the temperature is still normal, and 
remains high after the latter drops. This peculiarity 
of the pulse (designated as staffelformiger or Trep- 
penpuls) is regarded by all recent observers as the 
most important, in fact, the only early indication of 
beginning thrombosis. It was most characteristic in 
the fatal cases of pulmonary embolism, so that its 
persistence and accentuation are regarded as some- 
what ominous. Since it was not marked in my 
cases I infer that they belong to a different type 
from those on which Singer based his conclusions — 
in fact, the phenomenon seems to be most marked 
in pueperal phlegmasia. It would seem to point to 
a septic condition, in the diagnosis of which it is 
well known that the pulse is often of more value than 
the temperature. 

So far as my own experience has gone, a slight 
elevation of temperature (99.5° or 100° F.) is most 
apt to attract the attention of the ordinary observer, 
and, in the absence of evidences of trouble in the 
wound or within the pelvis, to lead to the suspicion 
that phlebitis is developing; but careful questioning 
of the patient will often elicit the information that 

^ VAbeilU Medicate, No. 53. p. 281. 1S96. 
' Loc. cit. 



slight stiffness of the leg was noted before any other 
symptoms appeared. 

The pain is often entirely out of proportion to the 
extent of the lesion. I do not know that it has ever 
been satisfactorily explained, unless we accept Simp- 
son's view that it is caused by stretching of the walls 
of the vessel. The early notion that it was due to 
an accompanying peripheral neuritis he positively 
rejected, though it is now held by careful observers. 

Edema is nearly always present, though it may be 
so slight as to be appreciated only on careful meas- 
urements of both limbs. In this respect my cases 
presented a marked contrast to the phlegmasia at- 
tending puerperal and post -operative septicemia. 

The prognosis in the class of cases which I have 
described is favorable as regards both a rapid recov- 
ery and complete disappearance of the local trouble; 
but the experience of the German surgeons whom I 
have quoted serves to emphasize in quite a startling 
way the fact that thrombosis following aseptic celi- 
otomy is a complication which cannot be regarded 
with indifference. The sudden onset of pulmonary 
embolism in patients whose condition had not previ- 
ously caused the slightest anxiety furnishes a forcible 
commentary on the uncertainty of the prognosis, as 
well as the absolute helplessness of the surgeon. 

In regard to treatment it cannot be said that the 
usual local applications or general medication influ- 
ence the course of the affection, either by limiting 
the extent of the thrombus, or by hastening its reso- 
lution. Absolute rest in the recumbent posture 
without manipulation of the affected limb, although 
irksome to the patient, is the most important point. 
We are apt to yield to her importunities, and to al- 
low her to sit up too soon. The disappearance cf 
the local pain, induration, and edema, and the con- 
tinuance of a normal temperature for several days 
are usually regarded as indicative of complete re- 
covery; but as long as the pulse remains at 90 or 
100 it is well to err on the safe side, and to keep 
the patient in bed a few days longer. Singer 
even insists that the recumbent posture should be 
maintained for at least three weeks after the pulse 
has become normal. Although this caution may 
seem to be extreme, it will at least prevent a relapse, 
with the consequent annoyance to the patient, even 
though the risk of pulmonary embolism may be so 
slight as to be disregarded. 



The Population of Puerto Rico Increasing. — At San Juan 
during the month of May, 1S99, there were si.xty-four 
births. During the same month of the previous year 
there were only forty. At Ponce, during the month of 
May, 1899, there were eighty-nine births. During 
the same month of the previous year there were fifty- 
two. 



July i, 1899] 



OTITIS OF THE EXANTHEMATA. 



OTITIS OF THE EXANTHEMATA FROM THE 

STANDPOINT OF THE PEDIATRICIAN 

AND GENERAL PRACTITIONER.' 

By J. HENRY FRUITNIGHT, M.D., 

OF NEW YORK. 

In my experience, covering a quarter of a century 
and embracing nearly 5000 cases of the exanthe- 
mata, especially scarlet fever and measles, I have 
met with otitis media as the most frequent of the 
various complications which may occur during the 
course of these diseases. Of these patients, fully 
one-third were victims to a greater or less degree ot 
this particular complication, and of these twenty- 
eight were bilateral. These cases naturally varied 
in type of severity both as individuals and as expon- 
ents of different epidemics. Nor was the frequency 
of the occurrence of the complicating otitis in a di- 
rect ratio to the severity of the general constitutional 
symptoms of the infection as, a priori, one might be 
led to expect. For often have I encountered this 
complication in cases of comparatively mild infec- 
tion, and conversely, those exhibiting symptoms of a 
graver form very frequently escaped without this or 
any otner complication developing. In those 
highly malignant cases which run their course and 
terminate fatally in a period of from of eight to 
twenty-four hours, I have never seen this complica- 
tion because the patient succumbed before a suffi- 
cient length of time had elapsed to permit its devel- 
opment. In general terms it may be affirmed that 
complicating otitis is very apt to be developed in 
those cases which have much irritation, congestion, 
or inflammation of the faucial mucous membrane, 
the anatomical relations primarily favoring this, and 
the activity of the specific infection promoting the 
development of this complication, and if adenoids or 
large tonsils be present this liability to the develop- 
ment of otitis is accentuated. 

If these cases of otitis media complicating the ex- 
anthemata were always treated by the attending phy- 
sician from the very onset of symptoms a great many 
of the patients could be cured with less suffering and 
with less chance of the occurrence of possible defec- 
tive hearing or even total deafness. Too often when 
the patient complains of pain in the ear does the physi- 
cian ignore the significance of this symptom, and later 
when the ear symptoms have become urgent it is rec- 
ognized that valuable time has been lost in not having 
treated the complication when first the little patient 
began to complain, for I I'.ave often cut short an at- 
tack or at least mitigated its severity and preserved the 
patient's hearing by at once treating this complica- 
tion at its very commencement. With me it isrou- 

1 Read before the Section on Pediatrics of the New York Acad- 
emy of Medicine, May 11, 1899. 



tine practice in every case of the eruptive fevers to 
watch the ears of the patients, knowing as I do how 
frequently otitis occurs as a complication and what 
deplorable results to the auditory apparatus may fol- 
low the affection. Those cases which are left un- 
treated or which are perfunctorily treated will very 
often invite involvement ot the mastoid process. In 
my hands this has never occurred, for my cases were 
always treated as soon as the first symptom appeared, 
thus cutting short the progress of the inflammatory 
process. If the attack be treated immediately upon 
its appearance I have not found it necessary to call 
in the aid of an otologist. Some cases which I did 
not see from the very beginning of the attack of the 
exanthem did require later the services of the aural 
specialist. I can recall one case in particular in 
which operation was performed by Dr. Herman 
Knapp, who went down through the mastoid process 
to the brain itself and removed an exudate from the 
outer surfaces of the lateral cerebral sinus. The child, 
marvelous to say, did not die. This child had de- 
veloped a particularly severe otitis media during an 
attack of measles, resulting in this extensive caries 
of the mastoid process. She was not under my care 
during her attack of measles. It is but proper to say 
that this child showed lively traces of a tuberculous 
taint, and Dr. Knapp expressed the opinion that the 
mastoid disease was tuberculous in character. 

And this suggests another point, for I observed 
that those children who were the subjects of a con- 
stitutional taint, as tuberculous, rachitic, syphilitic, 
and what would in former days have been designated 
scrofulous or strumous, were very prone to the devel- 
opment of this complicating otitis. I have already 
written in extenso concerning the treatment of com- 
plicating otitis media in the Transactions of the 
American Pediatric Society for 1889, and in an arti- 
cle read before the Northwestern Medical and Sur- 
gical Society of this city, and published in the Med- 
ical News, Vol. 69, 1896, so I shall not enter into 
its details. There are, however, a few points in the 
treatment on which I shall touch. 

First, it is extremely important that scrupulous at- 
tention be given to the active treatment of the nose 
and throat in these cases, for thereby an attack of 
otitis is very often prevented. In regard to the 
question of paracentesis tympani I do not think 
that it is always necessary to incise the drum mem- 
brane. If, however, on inspection we can satisfy 
ourselves that the tympanum is projecting and is 
highly congested, and the patient is frantic with 
pain, then the membrane should be incised to relieve 
the engorged blood-vessels. These cases, however, 
are not so very common. When it has been neces- 
sarv to do this I have made the incision myself. 



PERMANENT SEPARATION OF THE AMNION AND CHORION. 



[Medical News 



Those cases which are slow to suppurate are in my 
experience the ones requiring this procedure. It 
has been seldom necessary in my experience to incise 
the drum membrane in suppurative cases, for many of 
such cases would perforate without warning. If the 
attendant does not have sufficient confidence in his 
ability to inspect the aural canal with the head mir- 
ror and hesitates to incise the membrane, then he 
should in the interest of the patient and for his own 
protection seek the advice and skill of the ear spe- 
cialist. 

The effort, however, should always be made to 
abort the attack and to hinder suppuration and per- 
foration, because when the complication shall have 
gone to this extent the time needed to cure it will 
have been much augmented and the difficulties in- 
volved in its cure will have been increased many 
fold. As already intimated, those patients who are 
subjects of a constitutional taint, and in whom the 
otitis has been left untreated and allowed to go on 
to perforation, are very apt not to get well, but 
become chronic cases and lose their audition. For 
the accompanying otorrhea I have latterly followed 
the following plan of treatment: First, five drops 
of peroxid of hydrogen are instilled in the ear; 
after a few minutes this is flushed out with lukewarm 
water until the water returns clear, free from all tur- 
bidity; the canal is then carefully dried out with 
pledgets of absorbent cotton. Then three drops of 
an alcoholic solution of boric acid is put in the ear 
and allowed to remain there. The strength of this 
solution is from five to ten grains to the ounce of 
alcohol. In most cases this treatment has been suc- 
cessful in checking the purulent or seropurulent dis- 
charges, though I caution the nurse that the treat- 
ment must not be discontinued so long as there is a 
vestige of the discharge. 



CLINICAL MEMORANDUM. 



PERMANENT SEPARATION OF THE AMNION 

AND CHORION IN THE M ATU R E AF TER- 

BIRTH. FORMING DOUBLE FETAL 

SACS . 

By J. B. NICHOLS, M.D., 

OF WASHINGTON, D.C. 

In the early period of pregnancy the amnion and 
chorion are separate membranes and inclose separate 
(concentric) cavities, the amnionic and chorionic. Later, 
about the third month, the amnion becomes closely ap- 
plied to the chorion, and the two membranes grow to- 
gether, obliterating the chorionic space. It rarely hap- 
pens that the primitive separation cf the amnion and 
chorion persists throughout pregnancy, so that the fetus 
is enveloped in two separate sacs, the amnion internally 
and the chorion (united to the decidua) externally. 



In April, 1899, I obtained for microscopical purposes, 
through the kindness of Dr. W. G. Suter, a human pla- 
centa with membranes and cord. The afterbirth was 
fully matured, and from a normal labor at full term; un- 
fortunately further details of the maternal history could 
not, when later sought for, be ascertained. On exam- 
ination this afterbirth was found to exhibit the abnormal- 
ity of having the amnion enurely separate from the 
chorion, so that the fetus was surrounded by two sep- 
arate sacs. The outer sac corresponded to the ordinary 
fetal membranes, proceeding from the margin of the pla- 
centa about the fetus ; microscopical examination showed 
this to consist of the chorion and decidua vera, the am- 
nion, which is ordinarily attached to the inner surface of 
the chorion, beingmissing. The inner sac was, as shown 



Fig. 




Afterbirth with double sac. i. Outer sac — chorion and decidua 
2. Inner sac— amnion. 3. Chorionic cavity. 4. Amniotic cavity- 
5. Placenta. 

by the microscope, the amnion ; it was given off from the 
placenta immediately around the insertion of the umbil- 
ical cord, and was thence reflected over the cord and 
fetus. A broad interval intervened between the amnion 
and chorion, and the surface of the placenta was not cov- 
ered by amnion. The condition is exhibited diagram- 
matically in the accompanying sketch. 

In such cases of double fetal sacs two separate dis- 
charges of the waters may occur, giving rise to a form of 
hydrorrhea gravidarum, or what was formerly known as 
"false waters." 

The condition under consideration is a rare anomaly of 
the afterbirth, and one that is not specifically mentioned 
in standard works on obstetrics. I have found seven 
other cases of this abnormality on record, as follows: 

Jorg, J. C. G. Schriften zur Beforderung der Kennt- 
niss des menschlichen Weibes, 1812, part i, page 279. 

Logan, C. A. Leavenworth Medical Herald, De- 
cember, 1S68, page 296. (two cases). 

Chesney, J. P. Leavenworth Medical Herald. Jan- 
uary, 1869, page 346. 

Gilbert. Detroit Lancet, 'i:io\e.vaber. 1879, page 204. 

Wood, Thomas. Transactions of the Edinburgh Ob- 
stetrical Society, -^oX. XIII., page 126. 



July i, 1899] 



MEDICAL PROGRESS. 



13 



Bowen, W. Sinclair. Transactions of the Washing- 
ion Obstetrical and Gynecological Society, Vol. IV., 
page 47. Dr. Bowen's specimen is in the Army Medical 
Museum. 

MEDICAL PROGRESS. 



the urethra was gradually dilated, 
after effects. 



There were no bad 



Metastatic Pyemia from Trivial Causes. — Under the 
above caption, McGregor-Robertson and McKen- 
DRICK. {Practitioner, May, 1899) give the most mterest- 
ing details of a case of pyemia, which in two weeks 
brought about the death of an unusually vigorous man of 
si.xty years of age. The only cause which could be as- 
certained for the entrance of the germs was a boil, which 
had arisen on the back of his neck a month previously, 
and which had entirely healed. Two or three smaller 
boils in the vicinity of the primary one were still active, 
but they were so insignificant that they were not con- 
sidered etiologically, and the correct diagnosis was not 
made until the eighth day of the disease, when an ab- 
scess appeared in the right forearm. Two days after- 
ward abscesses developed in the left wrist and right 
shoulder, and a pelvic abscess which gave no symptoms 
during life, w&slound post-mortem. In the begmning of 
the attack the fever was slight, the tongue was coated, 
and there was a very slight heart murmur. The suspi- 
cion of enteric fever was aroused. On the third day 
there was retention of urine, easily relieved by a silver 
catheter, and pelvic and abdominal examination showed 
no possible cause for the retention, other than a slight 
tenderness over the kidneys. The amount of urine was 
from that time on small, and the sediment contained 
some casts, so that nephritis was also considered. The low 
fever continued, and the heart's action became quicker, 
feebler,and moreirregular,and when the abscess appeared 
in the arm, the diagnosis of malignant endocarditis was 
made. Multiple minute abscesses were found at autopsy 
in the lungs, liver, kidneys, and prostate gland. There 
was a moderate degree of old inflammation in the cardiac 
valves, but none of recent date. Medical literature con- 
tams the records of a number of cases similar to this one 
in which fatal pyemia followed an apparently trivial in- 
fection. The source of infection in such cases has often 
been in a felon, but in the large majority the pyemia has 
resulted from infection about the mouth or in the tonsil- 
lar region. An initial rigor, which in the case of the 
writers' was only a chilly sensation, is an almost invariable 
first symptom of the pyemia. 

Removal of a Bougie from the Male Bladder. — GOLD- 
BERG (Centralbl. f. die Krank. der Ham. iind Se.vual- 
Org., April 22, 1899) divided a tight stricture with a 
Maisonneuve instrument. When he withdrew it, he 
found that the filiform bougie, which had acted as a guide, 
had remained in the bladder. The bladder was irrigated with 
mild antiseptic solutions for six days, a soft catheter being 
left in the urethra for two days. On the sixth dajf he 
saw the bougie through the cystoscope, lying acros^ IHli' 
urethral orifice. A small lithrotrite was passed and 
closed upon the bougie, which was readily extracted. 
Irrigations were kept up for a considerable time while 



Poisoning from Chloroform Decomposed by an Open Flame. 
— WiNSLOW {Boiton Med. and Surg, four., May 11, 
1S99) assisted at an obstetrical operation in a room I2x 
12 X 8.5 feet, in which there were three lighted gas-jets. 
Chloroform was used, but the fumes of the chlorin soon 
became so dense that the operation would have been 
abandoned had not all the windows been opened and 
ether substituted for the chloroform. Neither the physi- 
cians nor the patient suffered any permanent ill effects 
from breathing the gas, but the case ought to serve as a 
warning to others who administer chloroform in the pres- 
ence of a lighted lamp or gas-jet, without providing for 
the escape of the poisonous vapors which are caused by 
the decomposition of the chloroform. The danger may 
be avoided by selecting a large, well-ventilated room, and 
by keeping the chloroform well below the light, using an 
inhaler such as Clover's, Junker's or Snow's, which pre- 
vents the escape of chloroform into the room. The most 
peculiar thing about this case was the fact that no one of 
the physicians present at the operation nor several others 
to whom they spoke about it, divined the origin of the 
irrespirable vapors, and ether was substituted for chloro- 
form simply on the grounds that it was safer to use, as 
the operation would last longer than had been anticipated. 

A Physician's View of the Indications for Operation in 
Cholelithiasis. — Naunyn {Centralbl f. Chir., April 22, 
1899) affirms that cholelithiasis as seen in private practice 
is not so grave a condition as hospital practice leads one 
to think. He asserts that a favorable issue results in the 
large majority of cases without surgical interference. 
Certainly stones as large as a cherry can pass the common 
duct, and in many cases a fistula forms between the com- 
mon duct and the duodenum, and then still larger stones 
may pass. Indications for operation are given as follows : 

1. It is not justifiable to advocate operation in every 
case as soon as a diagnosis of cholelithiasis has been es- 
tablished, for operative interference does not guarantee a 
permanent cure, since stones may be left behind, or 
others form. 

2. Cases of acute cholecystitis with a greatly distended 
gall-bladder, as well as chronic cases of hydrops of the 
gall-bladder should be submitted to operation. 

3. Incases of chronic recurrent cholelithiasis, and 

4. In cases of obstructive jaundice operation should 
not be resorted to until a thorough Carlsbad treatment 
has failed. 

Gastrocolic Symphysis. — Bouveret {Rev. de Med., 
April, 1899) describes under the name of gastrocolic sym- 
physis, the drawing together of the stomach and trans- 
verse colon, which often follows chronic peritonitis either 
of a general character, or when localized in the region 
.?.ho'« the umbilicus. Extreme cases in which the 
st&rrch and colon are glued together throughout the 
whivi: length of the former are rare. In the ordinary 
case?, the attachment is not so close but may still give 
i\ rise to a set of symptoms sufficiently definite to warrant 



14 



THERAPEUTIC NOTES. 



[Medical News 



their grouping under a single name. Bouveret saw eight 
cases, in all of which the exciting cause was either cancer 
or ulcer of the stomach, and in all of which the adhesions 
were situated at the pylorus and extended to a greater or 
less distance along the greater curvature. The symptoms 
of pyloric stenosis were aggravated by the attachment of 
this part of the stomach to the liver, pancreas, or gall- 
bladder, while if the adhesions had caused the immobili- 
zation of a part of the stomach they set up the most in- 
tense pains. Adhesion to the liver was especially 
common when the trouble was due to a simple ulcer. 
There are two complications of this affection which can 
terminate life, a gastrocolic fistula and occlusion of 
the intestine. From a comparison of histories of sixty- 
two cases of fistula the following symptoms were noted : 
Fecal vomiting, the passage of undigested food (lientery) 
similarity of the vomited matter and the stools, profuse 
diarrhea, thirst, rapid emaciation, a fecal odor to the 
breath and to eructations, the sudden cessation of vomit- 
ing which has existed for a long time, or the sudden dis- 
appearance of a tumor which had existed for a long time, 
and the vomiting of injections. To these signs may 
be added the evidence ofifered by the inflation of the colon 
with air, through the rectum, and the results of the chem- 
ical examination of the stools. These signs do not all 
have an equal value. However, if the fistula is large 
enough to permit the free passage of fluids, the diagnosis 
will usually not be hard to make during life. Stenosis of 
the intestine may be produced by a band, by circular 
constriction, and by abnormal fixation, three factors which 
will be likely to be combined in various ways. The symp- 
toms are those of obstruction elsewhere in the large in- 
testine. Occlusion is usually incomplete for a long time, 
and the death is therefore a hngering one. In some pa- 
tients it is possible to make out that the increased peri- 
stalsis due to the obstruction has already begun in the 
cecum and ascending colon but has not yet extended to 
the small intestine. This partial peristalsis of the large 
intestine has a great value in diagnosis. It is well known 
in connection with pyloric obstruction, the stomach alone 
being involved in the increased movements ; but increased 
peristalsis of the small intestine has also been observed, 
though it is certainly rare. General peristalsis is the 
fourth variety of peristalsis and is of less value in diagno- 
sis than the partial ones. 

In operating upon a patient with gastrocolic symphysis 
a median incision above the umbilicus is to be preferred. 



THERAPEUTIC NOTES. 



Use of Salt Solution in Eclampsia. — AlleK {Amer. 
Jour, of Obsiet., May, 1899), having treated a number 
of eclamptic patients without the use of saline infusion 
and also a number by this method, says that it is impos- 
sible to realize its great advantages unless one has 
watched its results. He advocates for pre-eciamfflic 
treatment, thorough purgation, and warm baths twiiss^a: 
day, a milk and water diet, and sedatives. If the symp- 
toms do not improve, interference with pregnancy is ^astitr 
fiable. In cases seen after convulsions have begun, his. 



eclamptic treatment is to give morphin at once, and in- 
ject into the bowel i dram of bromid and 40 grains of 
chloral, to anesthetize the patient, using as little chloro- 
form as possible, and to empty the uterus, by forceps or 
version, to allow the patient to bleed from the uterus for 
a time and if not enough blood is lost in this way 
to open a vein. As soon as possible after delivery he 
introduces 700 c.c. salt solution under each mamma and 
if necessary he repeats the injections daily for several 
days. The only drug that seems efficient to move the 
sluggish bowels in this disease is croton oil in large 
doses. Two drops may be given in 2 drams of olive oil, 
the latter preventing the severe irritation which croton 
oil sometimes causes. As soon as the patient rouses 
sufificiently she is given dram doses of Epsom salts every 
hour, or an enema. Wet and dry cups may be applied 
over the kidneys, or a half ounce infusion of digitalis given 
every four hours. The diet is exclusively milk. A hot 
air bath or a wet pack is useful in stimulating the skin. 
During convalescence a tonic is needed. 

An Internal Plate for Ununited Bones. — POTARCA (La 
Presse Med., April 19, 1899) cuts down upon an ununited 
fractured bone, squares the two ends, and holds them in 
a correct position, closely approximated, by a thin metal 
plate which is screwed fast to each fractured end, just as 
one might mend a broken cane. The after treatment is 
very simple. Held together so accurately, the bones 
quickly unite, and when union is sufficiently solid, the 
plate is exposed by a new operation, the screws taken 
out, the plate removed and the new wound allowed to 
heal. There are no complications to be feared, if the 
plates are capable of being sterilized, and are made of 
some metal which will not decompose or form poisonous 
salts in the fluids of the human body. Nickel, almost 
pure, answers these requirements better than silver, pla- 
tinum, aluminum, or copper. This method of treatment 
is also recommended in recent fractures in which reduc- 
tion cannot be obtained or cannot be maintained. Thanks 
to the X-ray, the relations of the ends of the bone can 
be determined with exactness, and an immediate opera- 
tion be performed if it is found to be desirable. 

7he Thyroid Gland in Infectious Diseases. — Roger and 
Garnier (La Presse Med., April 19, 1899) examined 
the thyroid glands of thirty-three patients who died from 
infectious diseases — scarlet fever, measles, diphtheria, 
smallpox, typhoid fever, cerebrospinal meningitis, and 
septic peritonitis. It was not always possible to say how 
much of the alteration in any given case was due to the 
primary disease, and how much to the fatal complications. 
In general, however, there was congestion and hyper- 
trophy of the thyroid, with an increased and altered secre- 
tion, and in the only smallpox case examined, and in one 
of the diphtheria cases, there were foci of parenchymatous 
hemorrhage. Most of the changes were of such a char- 
acter that, had the patient lived, they could easily have 
.<pBen)iecovered from ; but other lesions suggested a per- 
aaauent derangement of the gland though just how the 
system could be affected thereby is impossible to state 
with our present knowledge of the pathology of the thyroid. 



July i, 1899] 



COCAINIZATION OF THE SPINAL CORD. 



IS 



The Medical News. 

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OF MEDICAL SCIENCE. 



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SATURDAY, JULY i. 1899. 

YELLOW FEVER; ITS DIAGNOSIS AND QUAR- 
ANTINE REGULA TIQNS. 

OuK relations with Cuba and the West Indies 
generally have become so intimate that every one 
has been looking forward with no little dread to the 
increased possibilities of yellow fever being imported 
into the States during the present summer. The re- 
cent outbreak of the disease in the garrisons at San- 
tiago and Cienfuegos, although limited in extent 
and rapidly brought under control, adds to the ap- 
prehension. 

Dr. Laine's article, which we publish this week, 
while giving the important practical points for the 
speedy recognition of yellow fever makes it clear 
that even, in experienced hands, the unfailing de- 
tection of the disease at its inception is a very knotty 
problem and one that cannot be solved with the 
ready facility that popular tradition usually assumes 

The points given by Dr. Laine cannot fail to b( 
of the greatest service, however, and the very fact thai 
those who are most familiar with the disease depre- 
cate the idea that any assured means of early diag- 
nosis of yellow fever exists, in the absence of an 



epidemic, will make medical men when suspicious 
cases come under their care all the more careful of 
making definite declarations until assurance beyond 
doubt or cavil is at hand. It is probable that owing 
to increase of commercial relations between the 
West-Indian islands and the mainland a certain num- 
ber of actual cases of yellow fever may be imported 
and that a number of insolation and choleraic cases 
that develop shortly after landing will be open to 
the serious suspicion that they are yellow fever. 
Under either of these circumstances it is important 
that diagnosis should be carefully considered and be 
absolutely assured before made public. The public 
health and the commercial interests of the country 
are dependent on it. 

It is unfortunate that we have not a uniform sys- 
tem of quarantine. Quarantine regulations at pres- 
ent are dependent on State governments and differ- 
ences are very notable. So long as the responsibility 
for the public health of the country is thus divided 
among many, loopholes for the entrance of epidemic 
disease are liable to be left unprotected, and the lack 
of a National Bureau of Health will be more and 
more felt in the immediate future. The Marine 
Hospital Service is doing all that can be expected of 
it, with its inadequate means and unsatisfactory 
authority. It is certain that the work accomplished 
by it even under these trying conditions is making 
clearer the advisability of committing the care of 
public health to a central bureau. 

The State government of Georgia has recently 
turned over to the United States Marine Hospital Ser- 
vice its quarantine at Savannah. The effective work 
done by this department in the Southern States at 
times of yellow-fever invasion during the past few 
years, certainly justifies this action and stamps it as 
a step in the right direction. It is to be hoped that 
other State governments will see their way to a 
movement in the same direction. LTnder present 
conditions and without the National Bureau of Health 
that we should have, this voluntary appeal to the 
Marine Hospital Service seems the action most 
suited to secure easily and promptly the uniformity 

ot!" --'larantine regulations. 
' essi ° 



' Tnfan. 

UOicnenU/fi/zATION OF THE SPINAL CORD. 
yi\ now nearly sixty years since the introduc- 
tioi'^e-. ijthe habitual employment of narcosis during 



16 



ECHOES AND NEWS. 



[Medical News 



operations by means of ether or chloroform. In 
view of the many inconveniences and dangers attend- 
ant on anesthesia produced in this way it is surpris- 
ing that, save for minor alterations, the methods in 
use to-day are practically those of Long, Simpson, 
and their contemporaries. The only real advances 
have been the facilitation of the first stage of etheri- 
zation by the primary induction of laughing-gas 
narcosis, the combination of oxygen with the anes- 
thetic, and improvement in the form of inhalers. 
Experience has shown that the various mixtures of 
ether and chloroform with the higher members of 
the petroleum group offers few advantages and real 
dangers, so that the ideal method of causing insensi- 
bility during major operations has not yet been at- 
tained. 

A step in advance seems to have been made, how- 
ever, by Bier of Kiel who, in the Deutsche Zeitschr. 
fiir Chirurgie for April, relates his experience with 
an entirely new application of a local anesthetic to 
produce general anesthesia. By the bold expedient 
of throwing small quantities of very dilute cocain 
solution (0.005-0.01 gm. of cocain) directly into 
the spinal canal he attacks the nerve -roots and gan- 
glia themselves as well as the non-medullated nerve- 
trunks before their emergence Irom the spinal 
column and produces satisfactory anesthesia of the 
whole body beneath the nipple line. Insensibility 
is complete seven or eight minutes after the injec- 
tion, which is done after the manner of Quincke's 
lumbar puncture, made painless by a preliminary 
Schleich's infiltration, and continues for about three- 
quarters of an hour. Strange to say, heat and cold 
perception and also the touch and pressure senses 
are preserved, but all impressions of pain are en- 
tirely obliterated. Because of this, and inasmuch 
as it seems incredible that the entire thickness of 
the large nerve trunks should be permeable by the so- 
lution in so short a time, the inference is drawn that 
the pain-conducting fibers are placed at the periphery 
of the ner\'e-bundle. 

Bier performed in this way such severe operations 
as osteoplastic resection of the ischium, knee-anr" 



Unfortunately for the vogue of the new method, 
however, the after effects are quite as undesirable 
and much more prolonged than those following 
chloroform or ether, and consist in dizziness, severe 
headache, nausea, and vomiting. As these symp- 
toms do not put in an appearance till a number of 
hours after the operation it is assumed that they are 
due merely to the disturbance of the cerebrospinal 
system and not to any direct toxic effect of the drug, 
and it seems probable that modification of the solu- 
tion employed may eliminate these difficulties. 

While in its present form suitable only for individ- 
ual cases where the use of the usual anesthetics is 
inadmissable, the idea is a very promising one and 
opens up a most suggestive field for investigation. 



ECHOES AND NEWS. 



Another Honor for Dr. Jacobi. — The Society of Obstetrics, 
Gynecology, ar.d Pediatrics of Paris, at its session, June 
2d, elected Dr. Abram Jacobi to foreign membership. 

Oysters and Typhoid Fever. — The report of the Health 
Oilncer for Brighton, England, states that "in 41.8 per 
cent, of the cases of typhoid fever occurring in Brighton 
during 1898, theie is a high degree of probability that sew- 
age-contaminated shell-fish were the cause of the attack.' 
This percentage is higher than in previous years. 

Dr. Cleai/eland Free. — The case against Dr. Trumbull 
W. Cleaveland, who was charged with ha\'ing caused the 
death of the child Irene Carhart, by improper prescribing, 
was dismissed on June 23d, the defense having put none 
of its witnesses or experts upon the stand. 

Cerebrospinal Meningitis in the United States. — At 
Shreveport, La., two deaths from this disease occurred 
during the week ending June loth, making a total of 
twenty-nine deaths from this cause since Januarj' i, 1899. 
In the District of Columbia five deaths were reported 
during the week ending June 20th. At Philadelphia for 
the week ending June 17th, four cases and three deaths 
were reported. 

A Yellow-Fever Cure ? — After independent experiments 
extending over a period of two years. Dr. Alvah H. 
Doty. Health Officer of the Port of New York, has pro- 
duced a serum corresponding to that of Professor 
Sanarelli which he considers both prophylactic and cura- 
tive in yellow fever. While using this serum it would be 
just as well not to neglect principles of sanitation such 
as General Wood has found an almost perfect safeguard 



ankle-joints, necrotomy of the tibia, resectionj^ 'I'ihe against the disease in Santiago, 
femur, etc., to the perfect satisfaction of the p^it/i- jites. 
By experiment on himself and a colleague**^^"hia3 



proved that the anesthesia was absolute and .' K^cp 



««st.. 



duction unaccompanied by unpleasant sensat,. »-'.'>* 



Germany' s Object-Lesson in Vaccination — Germany, with 
a population in 1871 of 40,000,000, lost during that year 
143.000 lives from smallpox. In 1874 the German Gov- 
ernment enacted a law making vaccination obligatory 
during the first year of life, and revaccination obligatory 



July i, 1899J 



ECHOES AND NEWS. 



17 



at the tenth year. The result was that the mortality 
from smallpo.x diminished rapidly, until now its victims 
number only 116 a year, and these cases are confined 
almost exclusively to the frontier towns. 

Contagious Diseases in New Yoric City The Board of 

Health makes the foUowingreport for the weekending June 
24, 1899: Measles, 330 cases and 12 deaths; diphtheria, 
198 cases and 30 deaths; laryngeal diphtheria (croup), 7 
cases and 3 deaths; scarlet fever, 130 cases and 14 
deaths; smallpox, 2 cases and 2 deaths; chicken-pox, 
21 cases and o deaths; tuberculosis, 165 cases and 145 
deaths; typhoid fever, 16 cases and 5 deaths; cerebro- 
spinal meningitis, o new cases and 7 deaths. 

7"Ae "Index Medicus." — The widespread regret felt be- 
cause of the possible abandonment of the Index Medicus 
has been partially dispelled by the prospect of the work 
being assumed by the American Medical Association. 
The resolution introduced at the recent meeting at 
Columbus that the Association take upon itself the editing 
and publishing of the Index Medicus has been referred 
to the trustees, who have taken it under serious consider- 
ation. As far as the benefit to the medical profession of 
America, or even to the world, is concerned, the Asso- 
ciation by undertaking this work would accomplish far 
more than by devoting its efforts and finances to the 
proposed erection of elaborate and expensive buildings. 

7/?e ••Philadelphia Medical Journal" and the American 
Medical Association. — Our Philadelphia contemporary takes 
a most hopeful view of the future prospects of the Asso- 
ciation. It says: "It is character rather than numbers 
that inspires us with hopefulness Even in such a matter 
as personal ethics and dignity there was at Columbus a 
most noteworthy absence of what has previously been an 
altogether too conspicuous presence of the guzzlers and 'all- 
nighters. ■ There were even strange stories of 'Nothing 
stronger than lemonade, please, this year!' and the ban- 
quets, even that of the so-called American Medical 
Editors, were free from stories in which the delight in 
witless filth has often been an astonishing element of at- 
tractiveness. There is plainly to be an end of the 'dry- 
smoker' and the roysterer. " 

Convention of Homeopathic Physicians. — The fifty-fifth 
annual session of the American Institute of Homeopathy 
opened in Atlantic City, New Jersey, on June 20th. 
There were over 1400 Hahnemannians in attendance. A 
report was adopted recommending that interference of 
opticians with the medical profession be deprecated. 
The following resolution was offered by General M. O. 
Terry of Utica, N. Y., ex-Surgeon-General of the Na- 
tional Guard of New York: ••Resolved, That in the 
opinion of this association, the oldest National medical or- 
ganization in the United States, the condition of the 
country and its standing among the progressive nations 
of the world demand for its medical department a posi- 
tion in the Cabinet equal in all respects to the other de- 
partments of the Government." 

Criminal Attempt to Avoid Service in the German Army. — 
The wealthy young men of Germany present a striking 



contrast to the same class in our own country. It is re- 
ported from Cologne that a number of prominent physi- 
cians and wealthy young men who have succeeded in 
being exempted from military service, unlawfully, are in- 
volved in a criminal case which is assuming alarming 
proportions. There are now seventy-two defendants. 
The trick in most instances was to render the men called 
for physical examination temporarily unfit by administer- 
ing strong doses of heart depressants sufficient to produce 
fluttering of the heart and other alarming symptoms. The 
Emperor has ordered a thorough investigation, without 
regard to whom it may hit. Several of the accused men 
are sons of rich Cologne bankers. 

Unselfish Devotion to Medical Duty. — The English med- 
ical journals commented recently in glowing terms on a 
very striking example of unselfish devotion to duty on the 
part of an English medical man. Dr. R. J. Burns of 
Sunderland was summoned to attend a man who had 
swallowed some phosphorus paste in beer. He came 
provided with a stomach-pump but the instrument un- 
fortunately was out of order. The doctor passed the 
stomach-tube and proceeded to empty the man's stom- 
ach by suction on the tube. His patient recovered only 
temporarily though so faithfully were the doctor's efforts 
that he himself has since been prostrated with some 
symptoms of phosphorus poisoning, partly from the effect 
of the fumes developed during the operation, and partly 
from actual absorption of the phosphorus through his 
oral mucous membrane. He has, however, now entirely 
recovered. 

American Troops in the Tropics. — Major George G. Gross, 
U. S. A., in a paper read at the recent meeting of the 
American Medical Association said : "In the selection and 
care of troops for the West Indies none but entirely sound 
men should be sent to these islands. No recruit under 
twenty-one years should be sent, and it would be better 
to make the minimum age twenty-two years. There 
should be no 'toughening' the troops on Florida sand- 
banks or by forced marches under a Virginia or Georgian 
sun. The transport service must be improved. At once, 
reaching the tropics, the men must be housed. The ra- 
tions should be modified. Still further changes are needed 
in the uniform. Something lighter than the khake uni- 
form for wear on marches and in the hottest weather. 
While it is true that the history of the Caucasian race in 
the West Indies is not encouraging, yet these islands pro- 
duced a Hamilton and a Josephine. Bad laws and bad 
social conditions, rather than the climate, have probably 
defeated the ends of Nature." 

The William F. Jenks Memorial Prize The fifth trien- 
nial prize oi $500, under the deed of trust of Mrs. Wil- 
liam F. Jenks, will be awarded to the author of the best 
essay on "The Various Manifestations of Lithemia in 
Infancy and Childhood, with the Etiology and Treat- 
ment." The prize is open for competition to the whole 
world, but the essay must be the production of a single 
person. The essay, which must be written in the Eng- 
lish language, or if in a foreign language, accompanied 
by an English translation, must be sent to the Col- 



i8 



ECHOES AND NEWS. 



[Medical News 



lege of Physicians of Philadalphia, Pennsylvania, be- 
fore January i, 1901, addressed to Richard C. Norris, 
M.D., Chairman of the William F. Jenks Prize Com- 
mittee. Each essay must be typewritten, distinguished 
by a motto, and accompanied by a sealed envelope bear- 
ing the same motto, and containing the name and address 
of the writer. No envelope will be opened except that 
which accompanies the successful essay. The committee 
will return the unsuccessful essays if reclaimed by their 
respective writers, or their agents, within one year. The 
committee reserves the right not to make an award if no 
essay submitted is considered worthy of the prize. 

Aseptic Duelling. — The newspapers announced recently 
that the well-known French author, CatuUe Mendes, had 
been wounded in a duel, the grounds for which had been 
the fact that he held the contradictory proposition to his 
opponent in the very important historical question. Was 
Shakspeare's Hamlet fat? Some of the details of the 
duel are of considerable interest to medical men. For 
instance, whenever the sword of either one of the duel- 
lists touched the ground the duel was instantly interrupted 
until the blades had been thoroughly sterilized by being 
passed through the flame of an alcohol lamp. What was 
especially feared and the reason for these minute precau- 
tions was contamination with tetanus bacilli. Not long 
ago a French surgeon issued a book giving the inde- 
spensable regulations for the proper conduct of a surgeon 
when summoned to a duel, which included the most rig- 
idly surgical sterilization of the duelling swords, and their 
careful preservation in a state of the most absolute asep- 
sis until the moment they were handed to the combat- 
ants, special care being prescribed that no hands came in 
contact with the blades before they were put to use. The 
interruption in order to resterilize whenever possible con- 
tamination is suspected is the very latest wrinkle and all 
up to date. Specialists in duelling surgery will, it is 
hoped, take note of this latest humanitarian addition to 
the surgical technic of the duel. 

The State Board of Charities and the Society for the Pre- 
vention of Cruelty to Children — Justice Barrett of the Ap- 
pellate Division of the Supreme Court handed down a 
unanimous opinion on Friday, June 23d, declaring that 
this Society is a charitable or eleemosynary institution, 
and as such subject to the powers of visitation and in- 
spection of the State Board of Charities. The very fact 
that such societies are clothed with peculiar and even 
extraordinary powers instead of indicating that the Leg- 
islature or the people meant to withdraw these societies 
from the supervisory powers of the State Board of Char- 
ities seems rather to suggest a conclusive reason why 
they should be supervised, and indeed quite as vigilantly 
as institutions possessing less power for good or evil. 
Mr. De Lancey NicoU, counsel for the Society, says that 
the present decision will not be accepted as final, but 
that the matter will be taken to the Court of Appeals. 
The investigation into the affairs of the Society which is 
being conducted before Albert Stickney brings out 
clearly that the police department and the district-attor- 
ney's office consider the Society to be not only useful to 



them but needful. At least one judge and one police 
magistrate declared that the Society's records were prac- 
tically indispensable when the question of the disposal of 
children came up before them. All of them were asked 
if they thought that a city department could accomplish 
as well the work now done by the Society, and replied in 
the negative. Certain recent newspaper allegations as to 
the shirking of taxes by the Society were shown on direct 
evidence to be practically without foundation. 

Obituary. — Dr. Thomas Osmond Summers, late sur- 
geon-major in charge of the fever hospital at Santiago, 
and a noted yellow-fever expert, committed suicide by 
shooting himself through the head at St. Louis, June 
19th. Despondency caused by the fancied lack of ap- 
preciation of his services by the Government during the 
Spanish War is supposed to have been the cause. Dr. 
Summers was Professor of Anatomy in the St. Louis 
College of Physicians and Surgeons, and was the author 
of several standard medical works. He gained an envia- 
ble reputation in his successful management of the yel- 
low-fever epidemic at Memphis in 1878. The agony 
of mind that Dr. Summers evidently suffered previous to 
committing the fatal act was shown by a most touching 
farewell letter to his wife, and his farewell to earthly ex- 
istence is forcibly and poetically expressed in the follow- 
ing lines, which were found after his death : 

PERDITI VITU.M — VALE MUNDUM. 

Good- night, Old World — Good-by to all your joys, 
Your sorrows, pleasures, passions, pomps, and noise. 
I leave you for the eternal silence of stars; 
The deepness of unbounded space where bars 
No longer hold the soul in durance vile. 
Where naught can wound and nothing can defile; 
Where the pure spirit shall despise the things 
The sense on earth hath loved. 
On wings bathed in the etlier of eternity. 
How sweet to feel from every passion free — 
And yet it is an awful leap to take. 
Into the great unknown perchance to wake 
To greater woes, indeed, than those we have 
And hoped to bury in the silent grave. 
But still the greater majority is there. 
Why then should we turn pale with fear? 
Or tremble when the hour supreme has come, 
As soon or late it must?^Man's final home — 
The grave — at least gives rest from troubles here, 
.^nd we may hope for sweet oblivion there. 
Then, Charon, come, I signal thee to-night. 
Come — row me o'er the Styx, I've lost life's fight. 

Osmond. 

,j Another Miracle by the Osteopath! — That the age of mir- 
acles or fairy tales has not yet passed away is shown by 
the following, which was telegraphed a few days since 
from New York to a Western newspaper, and duly ap- 
peared in its columns : One of the most unusual opera- 
tions yet recorded in surgery was performed recently on 
a young woman in this city, by which was effected the 
cure of a case of appendicitis. No knife was used, no 
medicine, no poultices, no ice-packs — none of the usual 
methods of physicians to treat this most serious of ail- 
ments. So simple was the method employed that only 
eight minutes elapsed from the time the physician reached 
the patient until he had completed his work, and, as he 
believes, successfully. The young woman is twenty 
years old, and belongs to an excellent family in Harlem. 
The doctor who performed the operation thus explains 



July i, 1899] 



THE AMERICAN MEDICAL STUDENT ABROAD. 



19 



the treatment : "The method of treatment is the one used 
by all osteopathists and has been in use by them for some 
time." To demonstrate, the doctor placed the thumb 
of the reporter's left hand flatly in the palm of his right 
hand. Then he slapped the palm of the hand smartly 
against the broad of the thumb. "The hand represents 
the psoas muscle," he said, "and the thumb the appen- 
dix. We produce a spasmodic contraction of the psoas 
magnus, like the slapping of the palm of the hand against 
the thumb. This forces the foreign substance from the 
appendi.x, and relief follows immediately. Just back of the 
appendix is the largest muscle in the human body, known 
as the psoas magnus. It is attached to the femur or big 
bone of the leg, and is the muscle by which one can re- 
volve the leg as a pivot at the heel. It is this muscle 
which is made to do the trick of emptying the appendix. 
Using the fingers of one hand to hold the walls of the ab- 
domen in place and to prevent a rupture of the delicate 
internal structures, with the other hand a spasmodic con- 
traction of the psoas magnus is brought about, which 
snaps it against the appendix and is said to force out of 
that organ whatever of foreign substances it may con- 
tain." Angels and ministers of grace defend us in this 
the dawn of the Twentieth Century ! 

Dispensary and Hospital Abuse — The agitation upon the 
subject of the abuse of dispensary and hospital charities, 
which has been created by the medical profession and 
vigorously maintained during the past few years, shows 
evidence of bearing fruit. The Dispensary Law, passed 
by the New York Legislature last winter, has placed in 
the hands of the State Board of Charities the power to 
correct abuses. This board, together with the New York 
City comptroller, is now taking active steps looking to im- 
mediate reformation of the present wasteful methods. 
Mr. Coler, the city comptroller, arraigns the present system 
of distributing charitable funds as follows : More money 
is contributed for charity than can be expended properly 
for charitable purposes and the result is the creation of a 
class of artificial dependents. (2) Enormous sums in- 
tended for the relief of the poor are wasted in costly 
buildings and large salaries. (3) Private charities, par- 
tially supported by the city, draw from the institutions 
wholly under city control to such an extent as to impair 
the latter's usefulness. (4) No adequate account is made 
of money received and expended. (5) Certain charities 
are run for the principal object of drawing money from 
the city and spending it. In support of the first count in 
his indictment the comptroller points out that while the 
pauper population of the city amounts to only one per 
cent, of the total, no less than seventy per cent, are re- 
ceiving medical treatment free of charge through charita- 
ble institutions. Public and private charity expends an- 
nually, in New York State, more than $20,000,000, in 
the support of unfortunates who are not criminals. More 
than one- fifth of this great sum goes for salaries alone. 
Speaking generally it costs, under the present method, 
$25 to distribute $75 in charitable work. Many of the 
charitable institutions of New York City make a practice 
of paying canvassers for contributions a percentage of 
all the money they bring in. The comptroller points out a 



striking instance of abuse in this connection. He is an 
honorary vice-president of the Moderation Society, the 
purpose of which is to supply ice-water in summer in or- 
der to prevent the use of intoxicants. The city appropri- 
ated for the use of this society, $250. A few days later 
Mr. Coler received a letter saying, that no doubt he would 
be glad to know that the man who brought the city's 
check to the society received $25, or ten per cent, of it, 
for his trouble. 



CORRESPONDENCE. 



THE AMERICAN MEDICAL S T U D E N T ABR AD. 

MEDICAL WORK FOR WOMEN IN VIENNA. 

To the Editor of the MEDICAL NEWS. 

Dear Sir: — Practically, a woman's opportunities in 
Vienna for regular medical work are as great as those of 
a man, although a few professors still refuse to admit 
women to their lectures and operations. The university of 
Vienna, founded in 1365, conferred its first degree upon 
a woman — that of Doctor of Medicine — in 1897. 

We made it a rule to ask permission of each professor, 
docent, or assistant, before entermg his clinic or operating- 
room, and thus were always sure of a friendly reception. 
We have been told that failure to observe this rule some- 
times resulted disastrously. Letters of introduction from 
eminent physicians may be of great value; letters from 
former students are generally disappointing, because, in 
the rapidly changing classes, names are likely to be for- 
gotten. A fair knowledge of German is, of course, in- 
dispensable to one's best work. If necessary, it is an 
actual saving of time to devote oneself, at the outset, to 
serious study of the language. 

The unlimited university course can be entered at any 
time by making application to the medical department of 
the university, but the courses most popular with foreign 
doctors are private ar.d are difficult, sometimes impossible 
of access. Many of these courses are organized, and 
in a measure controlled, by English or American doctors, 
to whom application must be made. It is advisable to 
arrange some time in advance for a place in a popular 
course, as places have often been engaged months, even 
a year before they were to be used. By writing to the 
Anglo-American Vienna Medical Association, I Landes- 
gericht-strasse 12, one can obtain the latest information. 
The regular university program and programs for vaca- 
tion courses are useful in planning one's time. 

The work in medical diagnosis isunequaled. It would 
be difficult to imagine a more thorough system of physical 
examination and instruction. One is filled with admira- 
tion for the skill of men who have for years enjoyed the ad- 
vantages of a free use of unlimited material, with oppor- 
tunity to test the diagnosis of every fatal case at the 
autopsy-table. The hospital wards are freely accessible 
to students, and one can spend hours daily in the study 
of cases with the most advanced aids to diagnosis at one's 
command. The clinical material both as to adults and 
children is enormous. There are fine advantages for 
studying infectious diseases, especially scarlet fever 



ABSENCE OF UTERUS, OVARIES, AND THE CLITORIS. 



[Medical News 



and diphtheria. The post-mortem room is open to all 
students. 

In the pathological and bacteriological laboratories 
there is a vast quantity' of fresh material, with skilled di- 
rection in exhaustive macroscopical and microscopical 
study of pathological findings. Advanced students de- 
siring to do research work are cordially welcomed, 
and assisted in making an arheit worthy of the depart- 
ment. 

E.xcellent diagnostic courses m surgery, with operative 
work on the cadaver, are obtainable. It is possible in a 
few clinics to get minor surgical work, and some who 
have been willing to serve a couple of years in a clinic 
have had the privilege of assisting the professor at major 
operations, and also of performing a certain number. 

The courses in gynecology are very good and include 
e.xaminations under ether, some small operations, and 
general treatment ; larger operations are almost out of the 
question for doctors not regularly appointed as operatturs. 
The obstetrical advantages are confined to diagnostic 
work, with operative work on the phantom and cadaver. 
By special favor and large expenditure of time one may 
be allowed some deliveries, with a case or two of low 
forceps. The number of operateiirs has been so much 
increased during the past ten years that there is nothing 
left for students. By securing permission to visit the 
three obstetrical clinics — total deliveries in a year, nine or 
ten thousand — one can, in a short time, watch a large 
number of cases and see considerable interesting opera- 
tive work. 

On special subjects there are numberless courses, some 
of which are exceptionally good : for instance, exceedingly 
valuable skin clinics, and embryological and anatomical 
courses on special organs finely illustrated. One great 
advantage of medical work in Vienna is its concentration, 
making it possible to take a variety of work without 
the loss of time entailed in constantly traversing a great 
city. 

The criticism often justly passed on American students 
is that they spread their energies over too much ground, 
and by a multiplication of courses fail to get the best ad- 
vantages and privileges from any. 

Expenses naturally vary with a student's individual 
needs and tastes. The fee for each member of a course 
in obstetrics, gynecology, and operative work is 2>^ gul- 
dens, or about $i per lesson; for other work generally i 
gulden. The tickets for university courses cost only a 
nominal sum. German lessons range from 40 to 50 cents 
an hour, and sometimes it is possible to exchange English 
for German lessons. Room and board may be obtained 
for from §25 a month up, exclusive of various fees. 

In conclusion let me say that we were strongly advised 
not to go to Vienna to study as the prejudice against 
women in medical work was said to be too strong to 
make such an attempt worth our while. On the contrary, 
we cannot speak too highly of the unfailing kindness and 
generous hospitality extended to us as colleagues during a 
two-years' stay. 

Angenette Parry. 

New STork, June 19, 1899. 



RELAPSING MEASLES. 

To the Editor of the MEDICAL News. 

Dear Sir : — I have noticed in recent issues of the Med- 
ical News your remarks anent relapses of measles, also 
Dr. Coleman's letter. 

We have just had an epidemic of measles of an ex- 
tremely severe type, and I have been much interested in 
two cases, a brother aged fourteen, and sister aged ten 
years, who are neighbors. Both of the children, so their 
mother assured me, had undoubtedly cases about nine 
years previously, and were the only two cases out of six 
that did relapse. 

The boy was first attacked and had an extremely se- 
vere spell, with grave symptoms. He made a beautiful 
recovery, but about sixteen or seventeen days after- 
ward had a mild attack, the fever lasting only a day or 
two, and the eruption disappearing in about forty-eight 
hours. The little sister had a very mild spell, fever three 
or four days, with an eruption thinly spread over entire 
body. She was soon up and at school again. About one 
week later she developed the initial symptoms, and had 
one of the severest attacks I ever witnessed. She is now 
up and about, but wears dark glasses to protect the eyes. 

These two cases occurring under my eye offer this sug- 
gestion : Are not some people more liable, or rather more 
sensitive to infectious fevers? Is it not possible that re- 
lapsing measles occurs most frequently in those not ren- 
dered immune by a previous attack? 

I offer this as an observation and trust others will be 
heard from on the subject. J. C. Ballard, M.D. 

Natchez, Miss., June 20, 1899. 



CONGENITAL ABSENCE OF UTERUS. OVA- 
RIES. AND TH E CLITORIS. 

To the Editor of the MEDICAL News. 

Dear Sir: — We wish to report an unusual case of 
congenital absence of the organs of generation— uterus, 
ovaries, and also the clitoris. Jeanette T., aged twenty 
years, mulatto, well developed ; came from a healthy 
family. The general figure is that of a slender boy — 
shoulders square, hips narrow, legs slightly bowed. Mam- 
mary glands well developed. External genitals appear 
natural. The parts are well covered with hair, with 
growth peculiar to females. 

Digital examination revealed an apparent imperforate 
hymen, tough and fibrous, with slight elevation, or fold- 
ing near the center. On chloroforming, and using Sims' 
speculum, the following conditions were seen : The 
vagina was only a shallow pocket, with the meatus open- 
ing very near the center of the canal. The lesser labia 
appeared normal. No clitoris could be seen or made out. 

The bladder was emptied with a catheter, and using 
the instrument as a sound examination was made with a 
finger passed into the rectum. As high up as it was 
possible to reach neither uterus nor ovaries could be felt. 
Nothmg intervened between the finger and sound save 
the perineal body low down, and above only the walls of 
the rectum, and the bladder. After close search in this 
way and bimanually none of these organs could be made 



July i, 1899] 



PARTIAL CONSCIOUSNESS DURING ANESTHESIA. 



out. The pubic arch was an acute angle (exaggerated 
male), the anteroposterior diameter not more than 2/2 
inches. 

This woman (.') has never menstruated. Has suffered 
with periodic headaches, and has had an occasional at- 
tack of drowsiness. She stated that she had never felt 
passion for man or woman. 

J. A. James, M.D., 

T. H. James, M.D. 
Cheraw, S. C, June 17, 1899. 



PAR T/AL 



CONSCIOUSNESS 
TH ESI A. 



DURING ANES- 



To the Editor of the MEDICAL News. 

Dear Sir : — In the issue of your journal for May 20, 
1899, appeared a communication from Dr. H. H. Stoner, 
in explanation of the possibility of retaining consciousness 
during anesthesia in so far. at least, as auditory impres- 
sions are concerned, that in spite of its "e.xtremely fanci- 
ful hypothesis" has a great deal in its favor. It may be 
true, as you said in your editorial foot-note, that the 
neuron theory has never been extended to the psychic 
phenomena in print, but I must admit that I have person- 
ally held this opinion for some time. 

We know that brain substance is composed of neurons 
and neuroglia or brain-cells and matrix, each brain cell 
with its dendrites and its axis cylinder. The researches 
of Ma.x Schultze have pi oven that the nerve fibrils com- 
posing the neuroglia or ground-substance of the brain 
are continued directly through the axis-cylinder of the cell, 
thus forming a direct means of communication between 
all active brain-cells having medullated axis-cylinders or 
neuraxons. Sir W. R. Cowers' has shown that there is 
every reason to believe that the individual brain-cells or 
neurons have no direct communication by means of their 
dendrites, but lie separately embedded in the matrix, each 
neuraxon in close proximity to a dendrite, both possess- 
ing an afferent and efferent molecular motion respectively. 
Now, if besides this afferent molecular motion each den- 
drite has an actual motion, capable of making contact 
with its nearest neuraxon — and there is no reason why 
this should not be, though it might be hard to prove — 
we could then understand the mechanism for the trans- 
mission of nerve impulses through the brain. If we look 
upon the brain as a vast battery composed of millions of 
cells, each cell (neuron) having a positive (neuraxon) and 
negative pole, the latter having several shunts (dendrites), 
lying close to but not touching the opposite pole of its 
nearest cell ; if we assume some simple arrangement by 
which this positive pole becomes magnetic as soon as the 
cell is thrown into the circuit, thereby attracting the near- 
est negative shunt of some other cell and so throwing it 
into circuit, and so on from cell to cell, we have a simple 
explanation of impulse transmission in the brain, and 
this theory, whether right or wrong, must at least be 
considered plausible. Now, if this holds good for the 
sensory-motor part of the brain, there is no reason to 
doubt that it also holds good for the ideomotor pait, the 
psychic center."! in the cortex : for psychic, sensory, and 

* Brit. Med. fournal, November 6, 1897. 



motor phenomena are as interconvertible as the phenom- 
ena of electricity, light, and motion. As one writer has 
said: "We think as we feel, or think we feel; and feel 
as we think. If we feel a pain, we think we are ill ; and 
if we think we are ill, we feel ill." If hypnotism has been 
of no other practical value, it at least has proven the cor- 
rectness of the above statements, and all students of this 
psychic condition know how easy it is to change psychic, 
sensory, and motor phenomena one into the other. 

By means of this neuron theory I have been enabled to 
explain to myself, at least to my own satisfaction, how 
Heidenhain's theory of cortical inhibition during hypno- 
sis might be the correct explanation of these phenomena. 
I advance this not as an original idea, for in this age of 
omnivorous reading one hardly knows when one has an 
original idea, but as the outcome of reading and think- 
ing. Those who have studied hypnotism not only from 
a practical but from a theoretical point of view, no doubt 
have come to the conclusion that hypnosis is a mental 
state similar to that of preoccupation and reverie, when 
that mental activity called "attention" — 1 say activity, be- 
cause It is the result of will — is focussed on anyone thought 
or line of thought and thereby frees the lower sensory- 
motor centers from the control of volition, enabling them 
to perform work automatically and without conscious 
knowledge. If the theory of dendrite make-and -break 
contact advanced above be true, it can easily be seen 
how in the ideomotor centers of the cortex this dendrite 
contact of the neurons could be brought about by the 
psychic activity of attention, and that when this activity 
is focussed. as in preoccupation or reverie, or paralyzed, 
as in hypnosis, the entire mass of psychical neurons 
would have to become isolated from the rest of the brain 
cells, and that there would have to result an absolute and 
utter inhibition of volition on the one hand and an equally 
absolute inability to consciously recognize sensory irrita- 
tions, such as pain, on the other; such at least is the e.x- 
perience of all students of hypnotism, whether the theory 
advanced in explanation of it is true or not. Those who 
have studied the practical side of hypnotic phenomena 
know that chloroform is a great help in producing hyp- 
nosis where a simple focussing of the attention with 
proper suggestions has no effect, in fact the inhalation of 
a few drops of chloroform with the simple suggestion of 
"shut your eyes and go to sleep" repeated a few times, 
often has the effect of at once producing deep hypnosis 
with peripheral anesthesia. If the anesthetic is now 
withdrawn, the patient is in the hypnotic state, the mus- 
cles generally cataleptic, and under the control of the 
operator's voice ; if the anesthetic is pushed beyond this, 
the catalepsy disappears and the muscles become flaccid 
with absolute anesthesia, so that there is not even a cor- 
neal reflex, but the patient is still in hypnosis, subject to 
the operator's control, remembering frequently every- 
thing that happened in this state on waking, and waking 
at once at the operator's command. If the chloroform is 
pushed beyond this stage, then results chloroform narco- 
sis, and the subject is no longer under the operator's con- 
trol. 

Such is my experience with some six or seven cases, 



22 



NOTES FROM SWITZERLAND. 



[Medical News 



the first one happening some years ago, when I had a 
simple minor operation to perform and intended to use 
hypnosis for anesthesia, but could not get my patient un- 
der control, so decided to give chloroform. When fully 
anesthetized, as I thought, I handed the inhaler to an as- 
sistant and proceeded with the operation, amputation of a 
finger. When ready for the stitches, I had the chloro- 
form removed, so that it was used only a few minutes, 
and I was certainly surprised to hear the patient answer 
a question I put to him a little while later, when he still 
seemed fast asleep. I found then that he had never been 
chloroformed at all, but had been in a hypnotic sleep, 
and he obediently awoke at my command, with a pretty 
good memory of all that had, been said but with no rec- 
ollection of pain. Since then I have tried this experi- 
ment in several instances and lately had a case that af- 
forded ample room for study. I had a patient whom I 
desired to make somnambulistic in order to have her 
carry out post-hypnotic suggestions, but I could never 
produce sleep sufficiently deep, so I used chloroform, 
which frequently is a great help in such cases, and though 
it never produced somnambulism in this case, it at least 
gave me a good opportunity to study the effect of hyp- 
nosis and chloroform used together. 

From what I have written, it will appear that Tagree 
in the main with Dr. Stoner's explanation and yet I go 
further and claim that the operation done by Dr. Goldan 
was not done during chloroform narcosis but during hyp- 
notic sleep. 

John R. Rose, M.D. 
Eastman, Ga., June 22, 1S99. 



NOTES FROM SWITZERLAND. 

IFrom a Special Correspondent.! 

ANOTHER TOTAL EXTIRPATION OF THE STOMACH — 
INCREASE IN INSANITY IN SWITZERLAND — PRO- 
PORTION OF WEAK-MINDED CHILDREN — ILLEGITI- 
MACY — ALCOHOLISM AS A CAUSE OF MORTALITY. 

Berne, Switzerland, June 17. 1899. 

Another case of total extirpation of the stomach for 
carcinoma of the pylorus remains to be recorded. It was 
performed by Dr. Kocher in his clinic on Friday, June 
9th. The patient was a woman of about forty years of 
age, very emaciated and with marked cachexia. She 
had been under treatment for some time on the medical 
side of the hospital in order to prepare her for operation. 
Upon opening the abdominal cavity the case was thought 
favorable for a total removal of the stomach, on account 
of the absence of lymphatic involvement, so this was 
done, great care being exercised to save as far as possible 
all vessels concerned in the nutrition of the large intes- 
tine. The stomach was removed as a whole, including 
the;cardia and about 4 cm. of the duodenum. An anas- 
tomosis was then made between the esophagus and duo- 
denum and the abdominal wound sutured, leaving a small 
opening for a glass drainage-tube. 

The patient recovered from the operation very well. 
She was fed per rectum and was seemingly on the high road 
to recovery until the morning of the third day, when with- 
out apparent cause she died. At the autopsy it was found 



that in spite of the great care during the operation not to 
interfere with the intestinal circulation, there was a small 
area of necrosis in the wall of the transverse colon, suffi- 
cient to give rise to a mild peritonitis, which was enough 
in the poor condition of the patient to cause her death. 
The esophagoduodenal anastomosis was in good condition 
and partly healed. In all, the patient lived three and 
one-half days after the operation. 

This is really the second case of total extirpation on 
record. The Ziirich case was, strictly speaking, not a 
total extirpation since part of the cardia was left. Both 
the San Francisco case and the Berne case proved fatal. 
The great danger evidently is in the vast circulatory 
disturbance which is caused in the intestinal tract as well 
as the interference with the abdominal sympathetics. 

Switzerland is indeed a country of antitheses. It 
contains some of the grandest scenery and health-giving 
atmospheres in the world, and yet its people are troubled 
with some of the worst afflictions. Out of a population 
of a little over 3,000,000, its twenty State insane asylums 
contain, according to the last report, 6164 inmates, an 
increase of about 200 over the previous year. Females 
predominate slightly over males. The cost to the State 
for the keeping of each person is given as about 250 
francs (^48. 25) per annum. 

There are no laws for the commitment of the insane ; 
no judicial proceedings, such .as a trial before a compe- 
tent court or expert commission, is necessary. All that 
is needed to commit an individual to an asylum is the cer- 
tificate of one physician; whether he be an alienist or not 
makes no difference. 

The proportion of weak-minded children is also un- 
usually large.] Recent statistics have shown that in all the 
cantons of Switzerland there were in the primary schools 
13,155 weak-minded children. The total number of 
pupils in the schools at the time the figures were ob- 
tained was 463,548, so that in each 1000 there were 
16.5 who were in greater or less degree weak-minded. 
Aside from these, there were 7667 children who were 
lacking in development in some respect or other. Of 
these, only 1082 received special attention in special 
classes. 

It is said that one out of every five children born in 
Switzerland is illegitimate. The reason for this high rate 
of insanity and defective mental development among 
children may be looked for in the customs of the people. 
The Swiss cling to the customs of their ancestors even 
though the conditions under which their ancestors lived 
comfortably have changed so as to make their customs 
impracticable and bad now. The laboring class, includ- 
ing the farmer, works unusully hard, most of the work 
falling upon the women. The pregnant woman works 
just the same as the rest, and I have seen women clean- 
ing the streets of Berne who were apparently near full 
term. The children are also made to work hard. In 
consequence they are dwarfed and stunted, both phy- 
sically and mentally. 

Alcoholism is getting to be quite an important cause of 
death in Switzerland, as well as in France and Germany. 
For the first three months of the past year, namely, from 



Jui.v I, 1899] 



OUR PHILADELPHIA LETTER. 



January i to March 31, 1898, ihere were, between the 
ages of 40 and 59, 57 men who died from this cause. 
The total number of deaths among men of this age was 
378, so that 1 5. 1 per cent, were due to alcoholism. 



OUR PHILADELPHIA LETTER. 

[From Our Special Correspoudeut.] 

another death from faith-cure practices — a 
case of "sleeping sickness" in philadelphia 
— new laboratories of the medico-chirurg- 
ical college — fiftieth anniversary of the 
northampton county, pa., medical society — 
commencement of the university medical 
school — state board examinations — ameri- 
can neurological association — personal — 
vital statistics for the week. 

Philadelphia, June 26, 1896. 

Still another dupe of the "faith-cure" propaganda 
has exhibited his belief to a degree incompatible with the 
continuance of life. This time the victim was a middle- 
aged and, in other matters, apparently intelligent trades- 
man, a Mr. Joseph McCraig, who left his home in West 
Virginia and came to this city to place himself under the 
instructions and care of a local "faith-curist," William 
J. Randall, D.C.S. Although this William J. Randall, 
D.C.S., holds forth in handsomely appointed offices in a 
prominent office-building in this city, and from external 
appearances seems to enjoy a very fair degree of prosper- 
ity, all this availed Mr. Joseph McCraig nothing, and he 
died and was properly buried, for he happened to be suf- 
fering from an organic heart-lesion, with widespread evi- 
dences of compensatory failure. With infantile artless- 
ness William J. Randall, D.C.S. , wriggles out of the 
legal questions involved in Mr. Joseph McCraig's demise. 
"Christian Science," he remarks, "is teaching the gospel; 
healing the sick is the smallest part of it. I do not ad- 
minister drugs. God is the healer. I never say anything 
about charges. We think that preaching the gospel and 
healing the sick go hand in hand." He positively denied 
ever having received money from his late patient, either 
for reading the gospel or for healing, although he admit- 
ted that in other cases the amounts paid to him for 
"reading," whatever that may indicate, are according to 
the circumstances of the patient. As it could not be 
proved that he had prescribed medicines or received a fee 
for treatment without having the requisite license the 
coroner turned William J. Randall, D.C.S., loose to 
browse about on his old stamping-ground, and illegiti- 
mately collect money from other dupes possessing more 
hallucinations than sober judgment. 

In view of the present development of general interest 
in tropical diseases it is not without interest to note that 
a probable instance of i*frican "sleeping-sickness," or 
"negro lethargy," occurred in this city during the past 
week. The patient, a medical missionary, lately returned 
to this country from Africa, died in one of the city hos- 
pitals of an obscure disease contracted in the tropics, and 
thought to be a genuine case of that fatal malady known 
as "sleeping-sickness." The patient had spent the last 
nine years of her life in the Congo Free State, and was 
attacked eighteen months ago with a characteristic train 



of symptoms, such as facial edema, progressive wasting 
and loss of strength, bodily fatigue, torpor, intense 
apathy, and certain sensory and motor-nerve disturbances. 
The progress of these symptoms was uninterrupted, even 
after her return to a temperate climate, and the patient 
died after an illness of more than a year and a half. 
Post-mortem e.xamination failed to reveal any typical 
lesion of the disease in question, but this is not unusual, 
in view of our limited knowledge of the post-mortem 
conditions to be sought for. Nor was it possible to 
demonstrate in the blood embryos of the filaria perstans, 
which form of filariasis, it will be recalled, is conditionally 
mentioned by Manson as a possible etiological factor in 
the "sleeping-sickness" common among the negroes of 
the Congo and of Senegal. 

Work has begun on the new clinical laboratories of the 
Medico-Chirurgical College and Hospital. The design of 
the building will be a pure example of Grecian architec- 
ture; it will have a frontage of 72 feet and a depth of 99 
feet, and is to be 5 stories in height, constructed of Pom- 
peiian brick, terra cotta and brown-stone, on a steel skel- 
eton. The first floor is to furnish accommodations for a 
number of the hospital out-patient departments, a large 
general lecture-hall will occupy the second floor, and the 
three upper floors will be devoted to laboratories of chem- 
istry, physiology, anatomy, histology, and pathology. 
The cost of the new building is estimated at $125,000, 
and it is proposed to have it completed and equipped for 
the reception of students by the middle of next October. 

The fiftieth anniversary of the Northampton (Pa.) 
County Medical Society was celebrated June 13th, at 
Easton. Dr. Amos Seip of Easton, the only survivor of 
the twenty-two original members of the society read an in- 
teresting retrospective address on the history of the society. 
Addresses were also delivered by Dr. Charles Mclntire, 
the president. Dr. John B. Roberts, representing the 
Philadelphia County Medical Society, and by Drs. W. 
Murray Weidman of Reading, and L. H. Taylor of Wilkes- 
barre, and by prominent representatives of the clergy and 
bar in this State. 

The annual commencement exercises of the Medical 
Department of the University of Pennsylvania were held 
June 15th, in the Academy of Music, in conjunction with 
those of the other departments of this institution. De- 
grees of Doctor of Medicine were conferred upon 211 
graduates of the medical school, and the annual oration 
was delivered by Hampton L. Carson, Esq. The annual 
business meeting and banquet of the Society of the 
Alumni of the Medical Department was held June 14th, 
and the following officers were elected : President, Dr. 
Meredith Clymer ; vice-presidents, Drs. John H. Packard, 
James Tyson, S. D. Risley and Charles K. Mills ; secre- 
tary and treasurer. Dr. S. D. Wadsworth. About 100 
members attended the banquet, among those present 
being Dr. Thomas Dunn English, of the class of '39, 
famous as the author of the ballad, "Ben Bolt. " Speeches 
were made by prominent members of the faculty of this 
and other local medical schools. 

The examination of applicants for licenses to practise 
medicine in Pennsylvania began June 20th, simultaneously 



24 



OUR LONDON LETTER. 



[Medical News 



in Philadelphia, Harrisburg and Pittsburg, and continued 
four days. A general average of at least seventy-five per 
cent, is required to qualify before the three boards, regu- 
lar, homeopathic, and eclectic ; and the candidate must 
stand exammation on the subjects of anatomy, physiology, 
pathology, practice of medicine, surgery, materia medica, 
obstetrics, therapeutics, chemistry, diagnosis, and hygiene. 
The applicants this year numbered 380. 

The twenty-fifth annual meeting of the American Neu- 
rological Association was held at Atlantic City, N. J., 
beginning June 13th. Over 200 members were present 
to listen to the opening address by the president. Dr. 
James Hendrie Lloyd of Philadelphia. 

Among the prominent Philadelphia medical men who 
sailed for Europe during the present vi'eek were Drs. J. 
William White, W. W. Keen, and G. E. de Schweiniiz. 

The number of deaths in Philadelphia during the week 
ending June 24th was 379, a decrease of 44 from the 
preceding week and of 8 from the corresponding period 
of last year. Of the total deaths, 122 were of children 
under five years of age. The following new cases of 
contagious diseases were reported : Enteric fever, 48 
cases, 9 deaths ; scarlet fever, 36 cases, 3 deaths ; diph- 
theria, 5 1 cases, 20 deaths; and cerebrospinal meningi- 
tis, 2 cases, I death. The total number of contagious 
diseases reported this week was 57 less than the week 
preceding. 

OUR LONDON LE TTER. 

[From Our Special Correspondent.] 

MEDICAL COUNCIL AND FOREIGN PRACTITIONERS — 
PERJURY AT POST-MORTEM — LITERARY AND HIS- 
TORICAL MEDICINE — DECISION IN FAVOR OF A 
PHYSICIAN — DEATH OF DR. NORMAN KERR — 
ANOTHER AMBULANCE ACCIDENT — " CROSSED 
APHASIA." 

London, June 16, 1899. 

The General Medical Council was in busy session 
all last week under the presidency of Sir William Turner. 
Several matters of interest and importance were dis- 
cussed and passed upon, among them two which appeal 
to the profession outside of Great Britain. One of these 
was the une.xpectedly warm dtbate which sprang up over 
the mild suggestion of the Italian Ambassador, trans- 
mitted through the Foreign Office, that some sort of recip- 
rocal arrangement should be made for the mutual recog- 
nition of English medical degrees in Italy and Italian degrees 
in England. English medical men have long bitterly 
complained of the hardship of being obliged to secure the 
local degree before they are permitted to practise in Italy, 
where, of course, wealthy invalids of all nations swarm in 
colonies, and the committee to which it was first referred 
therefore hailed it as a joyful omen and reported favora- 
bly upon it. The storm of indignant protest that burst 
upon the committee evidently astonished it. "It is the 
thin end of the wedge;" "if we make this concession to 
Italy we shall be obliged to extend it to Austria, Spain, 
the whole of Europe, even the United States;" "what 
is the use of laboriously building up a high standard of 
medical education, and then throwing open thefiood -gates 



to the riff-raff of the medical world?" and like frenzied 
appeals poured in thick and fast. And the finishing 
touch was given when the supporters of the proposal 
only ventured to do so on the ground of humanity toward 
English travelers falling ill in Italy, who might suffer 
severely if they were obliged to depend solely upon the 
incompetent ministrations of the average ignorant practi- 
tioner of that benighted land. 

Altogether the debate was hardly creditable to either 
the breath of view or the courtesy of the English Medical 
Senate, although it is quite probable that having re- 
lieved their minds and expressed their insular contempt 
and scorn for " Eyetalians" and " furriners" in general 
(who may also perchance have had some small struggle 
of their own for a higher standard) their sense of fair play 
will assert itself and they will proceed to practically grant 
the concessions asked for — and then wonder why the 
foreigner aforesaid is not both grateful and affectionate. 

The other matter is the last act in that curious drama 
of alleged perjury in a post-mortem report, which was de- 
scribed in a former letter. A certain Dr. MacKay was 
ordered by the coroner to make an autopsy upon a child 
that had died suddenly. He did so and reported that 
death had been due to cerebral congestion, but the coro- 
ner was for some reason suspicious and ordered a second 
examination made by the district police-surgeon and an- 
other physician, who reported that the skull had not even 
been opened and that death was due to pneumonia. 
Whereupon Dr. MacKay was committed on a charge of 
perjury, but the judge before whom it was tried chose to 
regard it in the astonishing light of an ordinary "doctors 
differ" and dismissed the case. The mills of the gods 
were still grinding, however, and last Tuesday the gri<'t 
was delivered, after a hearing in person before the full 
council, in the shape of an order to strike Dr. MacKay's 
name from the Register, which deprived him of the right 
to practise in Great Britain. If the executive committees 
of some of our great national bodies only possessed this 
right of disciplining gross breaches of professional duty 
and honor what a bracing effect it would have on our 
medical atmosphere! 

The medical faculty of Cambridge has reconsidered its 
decision not to hold the usual vacation course in pathol- 
ogy, on account of the death of Professor Kanthack, and 
announces the course to begin July 6th and to continue 
six weeks under the charge of Professor Sims Woodhead 
and G. Strangeways Pigg. 

June I ith, was "Hospital Sunday," when most of 
the pulpits in London had hospital sermons preached 
from them ; followed by a collection for this great 
charity. The Lancet has issued its annual Hospital 
Supplement, giving an admirably clear statement of 
the purposes for which these funds are urgently needed in 
future and the uses which have been made of them in the 
past. 

One aspect of the literary activities of our English 
brethren is distinctive and worthy of imitation, and that 
is the prominence which is given in their society proceed- 
ings to the literary and historical aspects of medicine. 
Two papers of this character have been read before prom- 



JULVl, 1899] 



TRANSACTIONS OF FOREIGN SOCIETIES. 



25 



inent medical bodies during the past few weeks, one by 
Mr. Albert Doran, on "The Medicine of Shakespeare's 
Time, as Presented in His Writings," a witty and most 
ingenious piece of work, consisting chiefly of one contin- 
uous stream of "quotations in solution," as Charles Lamb 
called them. The other was an address by Dr. Vivian 
Poore, on "English Medicine in the Eighteenth Century," 
a most entertaining sketch of our fathers in medicine, 
their personalities as well as their work. A capital story 
is related of the famous Radcliffe, court-physician to 
Anne and William III., but celebrated for his most un- 
courtly manners. The king, who was suffering from 
dropsy, called him in and showing him his swollen legs 
asked him what he thought of them. The soothing an- 
swer was jerked back: "I would not have your Majesty's 
two legs for your three kingdoms." He was not called 
again to that case. It was Radcliffe who founded the 
great Radcliffe Library at O.xford, although it was his 
boast for a long time before his death that he had not 
read a book for thirty years. Indeed, a wit of the time 
declared that for Radcliffe to leave his fortune to found 
a library was like a eunuch endowing a harem. 

A case of some interest to physicians has just been 
decided in the courts. A clergyman refused to pay a 
bill of $35 for services rendered to his wife, mother, and 
son, on the ground that the doctor had not used "modern 
scientific methods of examination" and make a mistake in 
diagnosis. On taking one of the patients to Germany 
this mistake was set right and a cure promptly followed. 
We have all met just that variety of cleric and it is a com- 
fort to know that an unabashed judge ordered him to pay 
the account on the ground that the fact of his deliberately 
choosing Dr. Collins and putting him in charge of the 
cases implied confidence in his skill and rendered him 
liable for all reasonable fees until formal dismissal was 
made. Why is it that the class which pays the least, 
often indeed no fee at all, is always the readiest to turn 
against us and consult a quack? 

Dr. Norman Kerr, the well-known specialist in ine- 
briety and medical temperance reformer, died May 30th, 
at his home in Hastings. He was the author of more 
than twenty works on inebriety and kindred subjects, 
and probably did more to promote rational temperance 
and the medical treatment of inebriety than any other 
man of his time. We in America remember him grate- 
fully as the man who prevented the Keeley "gold-cure" 
swindle from getting a foothold in England, by quietly 
suggesting to the Government that Keeley should be re- 
quired to give a demonstration of the value of his method 
before a committee of the Society for the Prevention of 
Inebriety, upon patients furnished by it, a test which the 
wily promoter of course dared not submit to. and by his 
refusal stamped himself as a charlatan, so that the author- 
ities promptly declined to grant any permit for the open- 
ing of his institutions. 

A dinner was given to Sir William MacCormac last 
week by all the house-surgeons who had been under him 
at St. Thomas' Hospital during his twenty years of serv- 
ice. No less than seventy-seven of them were present 
at the banquet. 



It has long been noticed what a curious tendency rare 
cases have to occur in pairs or trios, and the same seems 
to apply to accidents. Only last week we reported a death 
in an ambulance, due to reckless driving, and this week 
comes the news of a similar accident at Liverpool. A 
man who had been injured in a street-accident was being 
taken to the hospital in an ambulance, when the horse 
took fright, ran away and collided with a lamp -post, and 
the patient was picked up dead. This time no blame 
was attached to the driver, but rather to the horse, 
which had only one eye and was known as a "shyer." 
So the coroner's jury passed a solemn vote of censure on 
the contractor for furnishing such a horse for ambulance 
purposes, and there the matter rested again. 

Dr. Byrom Bramwell has recently reported a unique 
case of "crossed aphasia" or loss of speech following a 
lesion of the left cortex, in a left-handed person, showing 
that the speech-center is not always situated on the right 
side of the brain in such individuals, although such is the 
general rule. He also confirms Collins' interesting ob- 
servation, that if the destruction of Broca's convolution 
be sufficiently gradual, aphasia does not follow, vi'hich he 
regards as due to the gradual "education" of the corre- 
sponding center on the other side of the brain. 

The Government Commission on Foad and Drugs is 
now considering measures for the stringent regulation of 
the use of preservatives in foods. It has been discovered 
that both fresh fish and meat often possess a slight but 
very persistent bitter taste, traceable to the use of for- 
malin. This, though not poisonous, is highly objection- 
able on account of its hardening effect on the proteids, 
especially when used in milk, rendering them difficult of 
digestion. 

TR ANSACTI ONS OF FOREIGN SOCIETIES. 
French. 

TREATMENT OF GUN-SHOT WOUNDS OF THE CHEST — 
EFFECTS OF RESECTION OF THE CERVICAL SYMPA- 
THETIC NERVE — OCULAR MASSAGE — CURE OF HE- 
PATIC HYDATID CYSTS— SUTURE OF A FRACTURED 
CLAVICLE — AN INCOMPLETE OPERATION FOR SINUS 
THROMBOSIS — OPINIONS ON THE BEST TREAT- 
MENT OF HEMORRHOIDS— RUPTURE OF THE THREE 
PARTS OF THE QUADRICEPS AT DIFFERENT PLANES — 
SUTURE OF THE AXILLARY ARTERY — WARM BATHS 
IN MENINGITIS COMPLICATING PNEUMONIA — WHEN 
MILK ACTS AS A POISON IN UREMIA — MISTAKE IN 
X-RAY DIAGNOSIS. 

At the Academy of Medicine, May 16, Lucas-Cham- 
PIONNIERE showed a man who two months previously 
had received a bullet in his chest. The ball had entered 
at the right side of the upper part of the sternum, and the 
direction of the wound indicated that it had passed through 
the right lung. There was expectoration of blood, and 
marked collapse. The patient was kept absolutely quiet, 
and the external wound was cleansed. Further than 
this, nothing was done, although the following day there 
were signs of a large effusion of blood into the right side 
of the chest. The patient recovered satisfactorily, and 
a radiograph showed that the bullet was situated near 
the twelfth rib. The speaker took the opportunity to em- 



26 



TRANSACTIONS OF FOREIGN SOCIETIES. 



[Medical News 



phasize the importance of absolute rest in the treatment 
of such cases. In abdominal wounds early surgical in- 
terference is demanded. In wounds of the chest, the re- 
verse is true, and the patient should not even be turned 
over for the purposes of auscultation. He should be 
kept horizontal, or slightly inclined if respiration is facili- 
tated thereby, and raorphin should be given to allay rest- 
lessness, and laxatives and, if necessary, stimulants. 

At the meeting of May 23d, Francois-Feank spoke 
of the effect of the division of the cervical sympathetic 
nerve upon the circulation of the thyroid gland, the 
brain, the eyes, and upon the heart. It is logical to 
believe, that the resection of the sympathetic acts at 
least as much to suppress the transmission of abnor- 
mal excitation of a cardiac or aortic origin toward the 
center as it does to suppress the centrifugal influences of 
the thyroid, brain or heart. Irritations of the cardiac 
and aortic fibers, as of all the fibers of the sympathetic, 
may produce circulatory changes which suggest the at- 
tack in Graves' disease, including thyroid vasodilatation. 
Consequently the total resection of the sympathetic can 
easily produce good results, especially in cases marked by 
refie.x disturbances of aortic origin. 

Darier said that ocular massage had proved of such 
benefit in stimulating the accommodation of hyperme- 
tropic patients, that several of those so treated had been 
able to lay aside their glasses. In hypermetropic strabis- 
mus, the amblyopic eye had been so improved that binoc- 
ular vision had become possible, thus aiding in the cure 
of the strabismus. The acuteness of vision of several 
myopic patients was increased, but the eyes themselves 
were not altered. In a certain number of cases of glau- 
coma the sight had also been improved by massage. 

At the session of May 30th, Dieulafov spoke of two 
patients whom he had permanently cured of hydatid cysts 
of the liver; the first, a man, by means of a laparotomy 
and extirpation of the cyst; and the second, a child of 
ten years, by aspiration of the cyst contents. He spoke 
of the relative merits of these two procedures. Puncture 
is only suitable for recent cases, and should be done with 
every precaution to prevent the escape of fluid into the 
peritoneal cavity. To this end a fine needle should be 
used, and the whole of the contents of the cyst should be 
drawn off at the first puncture. If the needle clogs before 
this end is accomplished, a second needle should be 
introduced, without disturbing the first, and the two with- 
drawn at the same time. 

At the Surgical Society, May loth, Sieur said that he 
had resected the ununited ends of a clavicle, and sutured 
them together with two threads of silk. The fracture 
was of eight-months' duration and separated the outer 
third of the bone from the inner two-thirds. After the 
suture the arm was fixed for a month. In sixteen months 
after the suture every trace of the fracture had disap- 
peared and the function of ihe arm was perfectly restored. 
Broca discussed a case of mastoid abscess which had 
been treated by Delanglade. He had opened the 
mastoid cells and then an extradural abscess, and be- 
lieved that he had gotten beyond the trouble until the 
signs of sinus phlebitis appeared on the following day. 



The lateral sinus was therefore exposed but not opened, 
neither was the jugular tied. After a secondary femoral 
osteomyelitis the patient recovered. Broca thought that 
the ligature of the jugular and the opening of the sinus 
would have saved the patient from this complication. 

At the session of May 17th, there was a discussion of 
the treatment of hemorrhoids, which was interesting as 
showing the very different opinions held by well known 
surgeons in regard to the treatment of this most common 
disorder. 

MoNOD. operating under chloroform, does not touch 
the external hemorrhoids and cuts off the internal ones, 
one at a time, with scissors, suturing immediately the 
cut mucous edges of each. A drain wrapped with iodo- 
form gauze is left in the anus. 

Reclus uses cocain and thinks it important to remove 
the external as well as the internal hemorrhoids. 

Pozzi said that it is advisable to respect, as much as 
possible, the mucous membrane. He, therefore, employs 
only ignipuncture in the treatment of hemorrhoids. 

TiLLAUX also uses the thermocautery in the same 
manner. He said that its only inconvenience is the pain 
which lasts sometimes for two or three days after its 
use. 

Ot'ENU advocated general anesthesia in order to keep 
the rectum of the patient still. Under cocain it is drawn 
up involuntarily, even though no pain be felt. He said 
that different operations were indicated in different cases. 
If hemorrhoids are particularly turgid, ignipuncture is a 
better treatment than e.xcision. Prolapse of the mucous 
membrane is a common complication which cannot be 
cured by the cautery nor by partial excision. Ignipunc- 
ture gives eschars, which do not come away for twelve or 
fifteen days, and its one advantage is in the economy of 
blood. The sole objection to Whitehead's operation is 
the difficulty in carrying it out properly; but that will dis- 
appear if the surgeon will accustom himself to its details. 
It is not followed by pam, and cicatri'.ation is complete 
in two weeks. He had never seen any contractions fol- 
low this operation. 

RouTlER said that there would be no danger of re- 
traction if the line of junction of mucous membrane and 
skin was respected. His plan is to ligate each hemor- 
ihoid at its base, and then remove the projecting portion 
with a thermocautery. 

PoiRlER described a case of rupture of the quadriceps 
tendon, in which the three different tendons of which the 
whole is composed were separated at different levels. 
The tendon was sutured, with a perfect result. As the 
end of the crural portion was interposed between the 
ends of the right anterior portion, the result by massage 
would have been inferior to that obtained by operation. 

May 24th, RiCARD spoke of the suture of the axillary 
artery which he performed in the course of an operation 
for the removal of the axillary glands. The axillary vein 
was resected for a considerable distance, and the artery 
was accidentally incised. A lateral suture of catgut was 
applied at four places. The result was apparently per- 
fect, there being no difference in the radial pulse of the 
two arms. 



JULV I, 1899] 



AMERICAN LARYNGOLOGICAL ASSOCIATION. 



27 



TUFFIER said that in his experiments on animals, 
suture of an artery was usually followed by a callous 
which so compressed the vessel as to make it impervious. 

Bazv said that he had resected five mches of the a.xil- 
lary artery with no ill effects, so that he considered ils 
suture unnecessary in such a case as the one under con- 
sideration. 

At the Medical Society of the Hospitals, May 12th, 
Rendu described a case of pneumonia complicated with 
meningitis occurring in a girl aged five years. Cold baths 
were used in the treatment and the patient was recover- 
ing from the pneumonia when she developed the symp- 
toms of meningitis, stiffness of the neck, contraction of 
the muscles of the jaws and limbs, elevation of the tem- 
perature, etc. Warm baths were substituted for the cold 
ones, and 100 c. c. of saline solution was injected daily. 
Calomel and bromid of potash were given in small doses. 
Under this treatment the child slowly recovered her 
health. 

May 19th, Renon said that he had found that a milk 
diet acted as a poison in certain cases of uremia, just as 
it did in certain cases of enterocolitis, and probably for 
the same reason. The diet, therefore, ought to be the 
same as that recognized as best in the latter trouble. In 
five cases where he had carried out this plan of treatment, 
giving rice water and bean soup without meat for several 
days, vomiting, diarrhea, and dyspnea had disappeared, 
and the albumin in the urine had been reduced to almost 
nothing. Later a leguminous and farinaceous diet was 
given, and after that a milk diet, a mi.xed diet being with- 
held until all danger had passed. 

At the session of May 26th, Beclere gave the results 
of an autopsy which illustrated the care which must be 
used in drawing conclusions from X-ray examinations of 
the abdomen. His patient was supposed to have a sub- 
phrenic abscess, containing air, but the air-space was 
found to be a displaced transverse colon, while the pain 
was due to pleurisy, and the enormous purulent expecto- 
ration, which was thought to indicate a connection be- 
tween the subphrenic abscess and the bronchi, came from 
the dilated bronchi of the right lung. A previous pneu- 
monia had apparently been the origin of the whole 
trouble. 

SOCIETY PROCEEDINGS. 



AMERICAN LARYNGOLOGICAL ASSOC I A T I N. 

Abstract of the Procctdings of the Twenty-Jirsi Annual 

Meeting, Held at Chicago, Illinois, May 32, 3J, 

and 24, iSgg. 

First Day — May 22D. 

The Association met in the rooms of the Chicago 
Medical Society, and was called to order by the Presi- 
dent, Dr. William E. Casselberry, who delivered an 
address. He said that the honored custom of an ad- 
dress from the chair affords opportunities for suggestion 
looking to the welfare of an organization and of the de- 
partment of medicine which it represents which would not 
find expression in any set paper or formal discussion. All 



are conscious of the change in the drift of laryngological 
practice during recent years, first, by the evolution of 
nasal pathology, and second, by the appropriation of the 
ear. From a physician treating affections of the throat 
and chest, the laryngologist is fast becoming a surgeon 
with a routine of practice limited to local measures as ap- 
plicable to the upper respiratory tract alone. While freely 
conceding that progress has been realized along surgical 
lines, he deprecated the tendency of the day to deal with 
the throat and nose exclusively in a mechanical way, as 
if they were organs detached. He believes it engenders 
narrowness of thought, and that, through habitual disuse, 
there is gradually lost to the physician much of that funda- 
mental knowledge of pathology and applied therapeutics 
which is so essential to the welfare of the patient. 

Do latter-day laryngologists, as a class, habitually en- 
deavor to establish the real diagnosis in the earliest de- 
monstrable stage of pulmonary tuberculosis? Are not 
such patients liable to come tirst before us with their ir- 
ritable throats, hacking cough, tendency to hoarseness, 
and inclination to rhinitis? It is not claimed that the 
laryngologist must of necessity embrace in his practice all 
pulmonary disease; that is a matter of choice, and ex- 
pediency, but it is urged that he be ready to apply all the 
arts of diagnosis, and that he be conversant with every re- 
source known to medicine in ihe treatment of pulmonary 
conditions for the benefit of cases of laryngopulmonary 
tuberculosis, laryngobronchitis, bronchial asthma in asso- 
ciation with ethmoiditis, and other conjoined patholog- 
ical conditions of the upper and lower respiratory tracts. 
Nor will it answer to omit attention to the heart, aorta, 
and mediastinal contents. Paralysis of a vocal cord 
through pressure on the recurrent nerve by an aneurism 
is a simple proposition, but more complicated ones which 
require a high degree of diagnostic skill are continually 
encountered. 

Regarding the treatment of pulmonary conditions, es- 
pecially tuberculosis, cases which are not complicated by 
affections of the throat are naturally claimed by the de- 
partment of internal medicine. It is not possible, nor even 
desirable, to draw an absolute line at this point between 
laryngology and internal medicine ; in practice they are 
bound to overlap, but conceding that if drawn anywhere 
it would be here, there remains a considerable proportion 
of pulmonary cases in which the upper respiratory tract 
is so far implicated that they fall naturally under the care 
of the laryngologist. Hence, as before said, he should 
be conversant with every resource known to medicine in 
the treatment of pulmonary states. He should be a good 
systemic therapeutist, and continue to cultivate the art of 
prescribing, realizing the uses as well as the limitations 
and abuses of internal medication. Above all, one should 
study the conditions of natural immunity and susceptibil- 
ity in order that having made an early diagnosis, one may 
direct the mode of life and place of abode best adapted to 
arrest the disease and overcome the susceptibility. This 
implies a ready familiarity with sanitation, hydrotherapy, 
climatology, and sanatorium resources and methods. 

All laryngologists are familiar with the many throat 
conditions which appear as salient features of underlying 



28 



AMERICAN LARYNGOLOGICAL ASSOCIATION. 



[Medical News 



systemic states, and yet in the overswing of the movement 
toward localism general pathological data, systemic ther- 
apeutics and hygienic aids are not always utilized to the 
utmost. How often is edema of the larynx merely sec- 
ondary to chronic nephritis ; and laryngeal ictus simply 
the forerunner of locomotor ataxia ? 

Dr. John W. F.^rlow of Boston read a paper, en- 
titled "Is the So-Called American Voice Due to Catarrhal 
or Other Pathological Conditions of the Nose? " He said 
that the so-called American voice is so often referred to 
that he thinks we are justified in making inquiry as to its 
nature and cause. Liability to nasal catarrh is considered 
to be the determining cause. Laryngologists are all agreed 
that it is the exaggerated nasal quality, the production of 
voice in the nose, the twang, which is its most notable 
characteristic, and a consideration of the larynx and 
fauces as factors can be omitted. It is not the thick, 
muffled voice of weak carrying power, such as occurs in 
cold in the head, but the high, penetrating, vibrating 
voice, indicating an openness of the nasal chamber, so 
that the voice made in the larynx finds its way into the 
nose. Any condition which hinders the passage of air 
into the nose, such as large tonsils, adenoid disease, post- 
nasal polypi, or tumors, enlargement of the posterior 
ends of the turbinals, tends to diminish the nasal reso- 
nance, and hence should not be considered as contributing 
to the production of a nasal voice. When we say we 
talk through the nose, we mean that we do not speak 
through but in the nose, and we may distinguish between 
the sound made when only the very anterior part of the 
nose is obstructed, as when the nostrils are closed by the 
fingers, and when the obstruction involves the turbinals, 
as in acute coryza, the former sound approximating more 
the nasal twang. 

The essayist then considered the effect of chronic ca- 
tarrhal conditions of the mucous membrane of the nose 
without hypertrophy, so often associated with a similar 
disease of the post-nasal space. In severe cases of long 
standing there may be anesthesia and paresis of the soft 
palate, which would diminish the proper activity of the 
muscles which shut off the fauces from the post-nasal 
space, and thus some of the tones which should be made 
in the mouth are involuntarily formed higher in the nose 
and acquire a nasal character. This is well known to oc- 
cur temporarily immediately after the removal of a large 
adenoid before the palate has regained its proper strength. 
Apart from the effect of the incomplete movement of the 
palate, the author does not see that an atrophic condition 
of the nose tends to make a nasal voice if the method of 
speaking is correct. If it is incorrect the nasal character 
should be more marked owing to the greater opportunity 
for vibration. 

For purposes of study he divided patients roughly, ac- 
cording to age, into, first, children up to twelve years; 
second, those from twelve to thirty years old, and third, 
those above thirty. There can be no question that the 
nasal voice is very common in the first class. The voices 
of young children at play or in the class-room are often 
very noticeable for their nasal quality. From twelve to 
thirty years of age there is an increase in the number of 



cases of obstructing septa and anterior turbinal hyper- 
trophy. Polypi are more common, and atrophic rhinitis 
with some paresis of the palate is also more frequent. 
He should say that the nasal voice is met with very often 
at this age. but not more frequently than in the preceding 
period, and certainly not proportionately to the increase 
in causative conditions. After thirty years of age the 
various pathological conditions continue, and the scleros- 
ing inflammations of the mucous membrane become 
more marked. As to the frequency of the nasal voice, 
his impression is that it is rather less common than earlier 
in life, perhaps in the sense that there is a larger propor- 
tion of voices with no nasal intonation, although there are 
many very marked examples of the nasal twang, while in 
the young the number who speak without any nasal 
twang is decidedly less. 

If the opinion is correct that the condition of the nose 
is not the principal factor in causing the faulty voice, 
physicians should certainly expect to be able in many 
cases to improve the manner of speaking without medical 
or surgical treatment of the nose. Many excellent sing- 
ers have throats and noses which are far from normal, 
and pathological conditions have more to do with the 
range and power of endurance of the singing voice than 
with its proper quality in the medium registers, and when 
used in moderation. 

He believes that anterior nasal obstructions are com- 
mon in all civilized races, and that there is no reason for 
thinking that any peculiarity in the American voice is due 
to what is possessed by others equally with ourselves. 
The parts of our country, where are the oldest centers of 
civilization and education, should be the places where 
most attention is paid to both the singing and the speak- 
ing voice, and this is probably the case, but in our old 
country villages distant from the populous centers the 
voices of the natives are well known to have the nasal 
twang without regard to the condition of the inside of 
their noses. 

Dr. James E. Newcomb of New York City read a 
paper on "Adenocarcinoma of the Nose," in which he 
reported the following case: Mrs. C. C, aged sixty-one 
years, widow, of American parentage, was referred to 
him on account of severe and persistent nosebleed. Her 
family history was negative, and her previous history was 
without apparent bearing on her condition when seen. In 
June, 1898, she began to have almost daily bleeding from 
the left naris. She had been subject for many years to 
severe colds in the head, and was inclined 10 attribute 
her troublesome symptom in some way to this fact. 
The bleeding always stopped of its own accord, and no 
operative interference had ever been necessary. On two 
occasions it had been quite severe, but on all others it 
had been a mere dribbling. In September she had blown 
from the nose what she described as a "fleshy bean," 
and which was in all probability a polyp of usual variety. 
She had lost some flesh and strength during the few pre- 
ceding months, but no more than could be accounted for 
by the continual though slight bleeding. At times there 
had been a slight watery discharge with an offensive odor. 
None was present at the time of examination. The lat- 



July i. 1899] 



AMERICAN LARYNGOLOGICAL ASSOCIATION. 



29 



ter showed a woman of large frame, but with a rather 
worn and debilitated appearance. Pharynx, naso-pharynx, 
and larynx presented nothing especially noteworthy. The 
right naris showed commencing senile changes. The 
left was considerably occluded. The middle turbinate 
was considerably enlarged, and the mucosa covering it 
appeared to be in a condition of polypoid degeneration. 
About it were two or three fleshy proliferations which 
bled rather easily upon manipulation with the probe. No 
granular enlargement could be found, and there were no 
manifestations of pressure symptoms. Under ten per cent, 
cocain a portion of one of the fleshy masses was removed 
and sent to Dr. Wright for examination. His report was 
adenocarcinoma. Removal was followed by a little more 
bleeding than is the case with an ordinary polyp, but was 
easily checked, and there was no unpleasant reaction. 

The patient was seen again in two or three weeks, 
when it was noticed that the mass had reproduced itself 
in the same situation. A second piece was removed as 
before. There had been no bleeding in the meantime. 
The report upon the second piece was to the effect that 
it consisted of edematous tissue, with some newly formed 
and perfectly granular structures, all of it granular and 
degenerate-looking, nothing definitely malignant, but cer- 
tainly suspicious. Patient was seen again for the third 
lime on March 13th of the present year. The same re- 
production of tissue was noted as before, but none was 
removed at this time. There had been two spontaneous 
hemorrhages during the week preceding this visit, one of 
them quite severe. 

The patient was made acquainted with the gravity of 
the situation, and the question of a radical operation was 
submitted fairly to her. Thus far she has been unwil- 
ling to undergo the ordeal. She was last seen early in 
the present month (May, 1899). During the last few 
weeks the daily dribbling hemorrhages have continued 
and at times there has been a perceptible offensive odor. 
The occlusion of the nostrils is gradually increasing. 
Her general condition seems to be about the same as be- 
fore. 

With this case the author mentioned six cases to be 
added to those enumerated in a table prepared by Dr. 
Hopkins. 

As to surgical measures, up to the present time two 
general operative procedures have been followed : first, 
removal of the superior maxilla, with more or less of the 
surrounding structures ; second, attempted starvation of 
the growth by cutting off its blood-supply. In pursuance 
of the latter end the external carotid has been ligated. 
He has been interested to learn of a modification of this 
procedure, first made by Dr. Dawbarn. He found, upon 
studymg the anastomotic circulation, that after simple 
ligation of the external carotid there were fully twenty 
channels, through which collateral circulation could be 
established. With a view, therefore, of still further cut- 
ting off the blood-supply, he conceived the idea of ligating, 
one after another, the eight branches of the external 
carotid, and then, as the trunk of the vessel was thus ren- 
dered useless, of resecting it entire. He has performed 
this operation sixteen times upon eight patients, a two- 



weeks' interval elapsing between the two operations in 
each case. It has been performed once or twice by 
others. While the period covered by this work is too 
short, and the number of patients thus operated upon too 
few to allow of decisive conclusions, the author believes 
that time will demonstrate the logic and effectiveness of 
this operative modification. 

Dr. A. COOLIDGE, Jr., of Boston followed with a 
paper, entitled "Removal of a Foreign Body from the 
Bronchial Tube Through a Tracheal Opening," and re- 
ported a case. The report illustrated the ease with which 
a foreign body can be removed from a bronchus. Pa- 
tient, male, aged twenty-three years. He had worn a 
tracheotomy tube for twenty years on account of stenosis 
of the larynx. His last tube was made of hard rubber, 
and was several months old. Twelve hours before ad- 
mission the tracheal tube had become detached from the 
shield, and had been inhaled, causing severe coughing, 
and distressed and noisy breathing, which, although less 
severe, was still present when he was admitted. Exam- 
ination by X-ray was negative. Patient was etherized, 
put on his back, with the shoulders over the end of the 
table, and the head held downward and rotated to the 
right side. The tracheal opening was enlarged down- 
ward. Not having any other straight tube of proper 
caliber on hand, the essayist used a urethroscope, half an 
inch in diameter, and three inches long, a little short foi 
perfect examination. This was passed through the 
tracheal wound with the stylet in place, turned down, 
the stylet withdrawn, and the speculum without any dif- 
ficulty pushed down the trachea to within about an inch 
of the bifurcation. For illumination a head mirror and 
reflected sunlight were used, and this illuminated the field 
perfectly. The foreign body was seen in the right bron- 
chus, the upper end about one-half an inch below the bi- 
furcation. It was seized with a long pair of alligator for- 
ceps introduced through the speculum, and removed 
without difificulty. The patient suffered no ill-effects 
from the operation. During the whole time respiration 
was carried on easily through the speculum, except in at- 
tempts at coughing at first, which soon subsided. There 
was no inconvenience from secretion. 

Dr. G. Hudson Makuen of Philadelphia reported an 
interesting case of stammering, exhibited the patient, and 
demonstrated the methods employed in treatment. 

Dr. M. R. Ward of Pittsburg read a paper on "Sep- 
tic Thrombophlebitis as a Complication of Peritonsillar 
Abscess," and reported two cases. 

Peritonsillar abscess, or quinsy, is a common throat af- 
fection, and while the natural tendency is for the disease 
to run a favorable course, his personal experience, to- 
gether with a study of the literature on the subject, has 
impressed him with the possible fatal complications that 
may arise in any case, and of the necessity of a more 
guarded prognosis. Bosworth has given by far the most 
complete account of the rare complications of this dis- 
ease. He inclines to the belief that the most frequent 
fatal complication is rupture of the abscess during sleep, 
the pus entering the air passages, producing death by 
asphyxia. The literature, however, would indicate that 



30 



AMERICAN LARYNGOLOGICAL ASSOCIATION. 



[Medical Nehs 



hemorrhage is the more common fatal complication, and 
that septic thrombosis, or thrombophlebitis is exceedingly 
rare. 

It is the exception raiher than the rule for the special- 
ist to be called upon to treat a case of peritonsillar abscess, 
or quinsy. This disease, by custom, belongs almost ex- 
clusively to the domain of the genera! practitioner, while 
the treatment, if instituted at all, is purely symptomatic. 
Surgical interference is condemned as extra hazardous; 
medical as inefficient, and the patient is usually dismissed 
with the comforting remark, that "the abscess will rup- 
ture in a few days, when his sufferings will be at an end." 
This is usually true, but occasionally a pneumonia inter- 
venes, when the physician is again summoned, and the 
disease then receives the full measure of his attention and 
skill. The patient dies, and the death certificate reads 
"death from pneumonia." The peritonsillar abscess has 
been entirely overlooked as an etiological factor in causing 
the death of the patient. 

The evolution of sinus thrombosis, cerebral and cere- 
bellar abscess as a result of mastoid suppuration, has 
been slow but sure. To-day the aurist and neurologist 
are fully alive to the possibility of such complications, and 
the condition is not an infrequent occurrence. An in- 
fective process in any portion of the body is liable to pro- 
duce a general infection. This takes place either through 
the lymph or blood channels. When the infection is con- 
veyed through the blood channels, we generally have to 
deal primarily with the thrombosis or thrombophlebitis. 
The thrombus is usually found in the veins in close prox- 
imity to the seat of the primary infection, though not 
necessarily so. 

The conditions favorable to thrombosis are altera- 
tions in the blood current, changes in the vessel walls, 
and alterations in the blood itself. Any one or all of 
these conditions may be present in a given case. The 
slowing of the blood current from narrowing of the ves; el 
by pressure from the inflammatory products without pre- 
disposes to the formation of thrombi. 

The number of published reports of cases of infective 
thrombosis, or thrombophlebitis, as a complication of 
peritonsillar abscess is exceedingly few. Bosworth, in 
his exhaustive treatise on diseases of the nose and throat, 
devotes a paragraph of five lines to this rare complication, 
and refers to cases having been reported by Rigal, Dide- 
lot and Kiemann. A careful review of the literature at 
the author's command adds nothing to the list referred to 
by Bosworth. 

The author then detailed two cases that had come 
under his observation. The paper served to show not 
only the possibility but the serious nature of thrombo- 
phlebitis as a complication of peritonsillar abscess, and 
of the necessity of a more guarded prognosis in the treat- 
ment of this disease. 

Dr. Thomas Hubbard of Toledo, Ohio, followed 
with a paper, entitled "Report of Cases of Peritonsillar 
Abscess Associated with Diphtheria." In cases of diph- 
theria of the mixed-infection type the initial inflamma- 
tory reaction of the tissues of the throat and lymphatic 
system is frequently such as to lead us to expect deep 



suppuration or peritonsillar abscess. There is frequently 
undetected superficial pus-formation along with coagu- 
lation necrosis, but peritonsillar abscess is a rare compli- 
cation of diphtheria. Two cases exhibiting both diph- 
theria and quinsy at the same time came under his 
observation within a year ; the more interesting of the two 
we give below. The case presented a general clinical 
history that very clearly demonstrated the vagaries of 
mixed infection, two different members of the family ex- 
hibiting types of infection ranging from simple sore throat 
to abscess and fatal diphtheria. 

The eldest son of a large family had sore throat and 
remained at home for a few days. Two younger chil- 
dren had attacks of mild tonsillitis, as described by the 
mother. No physician was called. A few days later a 
younger daughter developed typical diphtheria, and an- 
other had quinsy. About four days later the one was 
moribund from diphtheritic toxemia, and the other had a 
large peritonsillar abscess, with pseudomembrane over 
most of the throat. The abscess was incised and 
a large quantity of pus evacuated. The diph- 
theritic patient died within an hour of his first visit. 
The other received 4000 units of antito.xin and recovered 
after a very severe sickness. A baby sister developed 
diphtheria of the most virulent type and died within twro 
days of the diagnosis. 

This series of cases of mixed infection suggests that the 
virulence of the different bacteria, together with the age 
and natural resisting power of the patient, determines 
which type, false or true diphtheria, or peritonsillitis, 
shall predominate. In cases of this character, where pus 
is confined beneath tissue covered with a diphtheritic 
membrane, the question as to the propriety of early in- 
cision is an important one. The more that the surface 
is abraded the deeper will the diphtheritic infection pene- 
trate and the greater be the absorption of toxins. We 
should be guided by ordinary surgical principles, and 
first locate the pus accurately. It should be evacuated 
only througn tissue already devitalized by softening, and 
vascular tissue should be avoided if possible. 

The Association discussed in a symposium the rela- 
tion of pathological conditions of the ethmoid region of 
the nose to asthma. Dr. Henry L. Swain of New 
Haven, Conn., dwelt upon the pathology. He stated 
that an accepted theory is that there must be, first, an 
irritability of the bronchial structures which makes pos- 
sible the explosion of energy known as asthma. This 
hyperesthetic condition is frequently the result of disease, 
and the multiplied and oft- repeated attacks always induce 
disease, and consequently greater irritability. Secondly, 
we usually find some other structure is diseased or over- 
sensitive. An irritation or disturbance of it sets into mo- 
tion the spasm of the bronchial apparatus. Thus .ve find 
that one asthmatic has an irritable nose, another a stomach, 
another a kidney, or an ovary, and if to these vulnerable or- 
gans certain stimuli are applied an explosion results. But 
to connect the nose, stomach, or kidney with the bronchial 
tubes a third element must be brought in, namely, the 
vasomotor system, or, as it is more often put, the neu- 
rotic habit. 



July i, 1899] 



REVIEWS. 



31 



The author is inclined to believe that lesions of the 
ethmoid, or generally speaking middle turbinate region, 
are of an edematous nature. How rarely, if ever, does 
one see a case of genuine atrophic rhinitis with asthma? 
The lesions are, therefore, hypertrophic in character, and 
at first confined to the mucous membrane. In more than 
sixty cases purulent ethmoid disease has only existed 
three times, and in these it was secondary to long pre- 
vious existence of edematous tissue. Marked disease of 
the bony structures occurred in these si.xty cases some six 
or eight times without puiulent conditions, and was here 
also due to inveterate formation of polypi, which latter 
the author is led to believe is always the rule, namely, 
that the disease of the mucous membrane precedes that 
of the bone. Septal spurs and bends seem to keep up 
middle turbinate disease and increase the possibility of 
pressure, which seems in a great many cases to explain 
asthma. But in all, whether complicated or not, there was 
hypertrophic disease always present, and usually of the 
edematous type. Very often these edematous hyper- 
trophies were polypoid in form. We have merely to ex- 
plain the production of hypertrophies, edematous and 
otherwise, in these cases, to have the pathology of nasal 
lesions clearly discussed. When treating many of the 
pathological conditions in the nose, whether asthma ex- 
ists or not, the physician must often look outside of the 
nose, and many times outside of the body, for the causes 
which have led up to them. 

Dr. E. Fletcher Ingals of Chicago discussed the 
clinical phases. He has seen cases of asthma relieved 
quite promptly by the removal of polypi, the patients 
gradually improving for days or weeks without having any 
asthmatic attacks, until the polypi recurred. He men- 
tioned one patient who was peculiarly unfortunate in that 
he was a teamster, and whenever he went near the stable 
he had asthma. He had known patients who could drive 
on a dusty road behind oxen without having attacks of 
asthma, yet who could not ride behind horses without 
having it. He mentioned other patients who could ride 
bicycles no matter how much dust there was, but who 
could not ride behind horses. He cited the cases of one 
or two patients who assured him they had asthma on 
one side only. 

Dr. F. H. Bosworth of New York, in speaking of 
the treatment, said there can be no question but that ede- 
matous hypertrophy, polypoid degeneration and polypi in 
the nose are intimately associated with asthma, and the 
removal of these pathological conditions would relieve the 
attacks of asthma temporarily, or in some cases, perhaps 
permanently. Clinical observation teaches us this. He 
contends, and has for a number of years, that we can go 
further than this and say that ethmoiditis is an etiologic | 
factor in asthma. Oftentimes asthma is relieved tempo- 
rarily by the removal of polypi, then it recurs. Why ? 
Because the physician fails to recognize that nasal polypi 
are only symptoms, or manifestations, of the disease in 
the ethmoid cells, and in removing simply the polypi he 
has not clearly carried out the clinical indications. More 
radical operative measures are necessary to effect a cure 
of asthma. 



Dr. F. E. Hopkins of Springfield, Mass.. read a pa- 
per, entitled "Recurrence of the Tonsil after Excision," 
and reported a case. A careful search of the literature of 
the subject discloses several cases, but a wide variety of 
opinion is represented as to the frequency and cause of 
recurrence, as well as of its prevention. It is noticeable 
that few cases are alluded to by laryngologists, and that 
most of the references are of cases which w^ere published 
some years ago. The inference is that under general anes- 
thesia, now so commonly employed, a more thorough oper- 
ation is performed and recurrences must be even more 
rare than formerly. Among the causes of recurrence, 
aside from imperfect operation, are a tubercular or speci- 
fic dyscrasia, and an acute inflammation of the stump. 
This acute inflammation of the stump must take place 
soon after operation in order to result in recrudescence of 
the tonsils, as occurred in his own case ; yet Mackenzie 
mentions a recurrence following acute inflammation long 
after operation. 

Dr. E. Fletcher Ingals of Chicago reported a case 
of fibrolipoma of the epiglottis and base of the tongue, 
and exhibited the patient. 

Dr. D. Braden Kyle of Philadelphia reported a case 
of confined suppuration of the frontal sinus with spon- 
taneous rupture; and Dr. John O. Roe of Rochester, N. 
Y., followed with remarks on the presence of parti- 
tions and diverticula as a cause of retarded recovery in the 
treatment of diseases of the maxillary antrum. 

The following officers were elected for the ensuing 
year : President, Dr. Samuel Johnson of Baltimore ; vice- 
presidents, Drs. T. A. DeBlois of Boston, and Moreau 
R. Brown of Chicago : secretary and treasurer, Dr. 
Henry L. Swain of New Haven, Conn. ; librarian. Dr. 
J. H. Bryan of Washington, D. C. ; member of the 
Council, Dr. William E. Casselberry of Chicago. Place 
of meeting, Washington, D. C, in conjunction with the 
Congress of American Physicians and Surgeons, May, 
1900. 

REVIEWS. 



Defective Eyesight. The Principles of Its 
Relief BY Glasses. By D. B. St. John Roosa, 
M.D., LL.D., Professor Emeritus of Diseases of the 
Eye, New York Post-Graduate Medical School and 
Hospital ; Surgeon to the Manhattan Eye and Ear Hos- 
pital, etc. New York : The MacMillan Company, 
1899. 

Some years ago there appeared, in a series by various 
authors upon different subjects in medicine and surgery, 
a little book by the author of this volume, entitled "The 
Determination of the Necessity for Wearing Glasses." 
This now appears under^a title which better explains its 
object, very much enlarged, illustrated, and almost com- 
pletely rewritten, so thorough has been the revision made 
necessary by advance in knowledge of the proper pre- 
scription of glasses, especially in regard to simplicity and 
accuracy. The manualjwiU be found a reliable guide to 
the student as well as to'the^practitioner in ophthalmol- 
ogy, while the easy, almost colloquial style and system- 



32 



THERAPEUTIC HINTS. 



[Medical News 



atic arrangement of topics will add to its interest to those 
educated people and general practitioners who, without 
having a special interest in the subject, wish to know the 
principles upon which the prescription of glasses is based, 
and who will find with these a number of interesting 
cases from the records of an authority, and the illuminat- 
ing critique of an eminent ophthalmologist. The author's 
standpoint on muscular insufficiences may appear ex- 
tremely conservative. He says: "It has been reserved 
for our time to produce those, of whom the present 
author is one, who . . . have ceased to believe in 
the existence of any such condition as 'muscular asthen- 
opia.' " While this may seem to go too far, it is cer- 
tainly a step in the right direction, and away from the 
"heterophorias," "imbalances," and "graduated tenot- 
omies," which, of late, were rife. 

The International Medical Annual and Prac- 
titioner's Index. A Work of Reference for Med- 
ical Practitioners. Seventeenth year. New York : 
E. B. Treat & Co., 1899. 

The present number of the "Annual," like its prede- 
cessors, covers the entire field of medicine and surgery, 
giving in detail all of the important advances in medical 
science made during the past year, and. with full refer- 
ence to the original sources. 

This is one of the best of the yearly summaries, and 
each page is a convincing proof of the painstaking labor 
expended in the compilation of the work. We feel con- 
vinced that every practitioner needs a work of this de- 
scription as a means of reference and as a time-saver, 
when one considers the enormous annual contributions 
to medical literature. On the whole, the editorial work 
has been well done, and the busy practitioner will fine 
the book to be in constant requisition. 

Diet and Food. Considered in Relation to Strength 
and Power of Endurance, Training, and Athletics. By 
Alexander Haig, M.A., M.D., O.ton., F.R.C.P., 
Physician to the Metropolitan Hospital and the Royal 
Hospital for Children and Women. London : J. & A. 
Churchill, 1899. 

The author, whose views on diet have been suggested 
in a monograph on "Uric Acid as a Factor in the 
Causation of Disease," goes a step further in the little 
volume under discussion, and lays stress on the elimina- 
tion from all food of the poisonous xanthins and uric 
acid. He believes that diet, as at present used, is often 
the product of much ignorance ; the cause of a waste of 
time and money; that it produces mental and moral ob- 
liquities, destroys health and shortens life, and generally 
quite fails to fulfil its proper purpose. We are not told 
whether these evils will vanish before a diet composed of 
milk, cheese, potatoes, pulses, and "protene," such as 
the author recommends, nor are any facts adduced to 
prove his contention that "one ounce of albumen from 
vegetables, milk, or cheese will produce a greater ex- 
ternal result than a like amount of albumen from the tis- 
sues of dead animals." While the extreme theses of the 
deleterious nature of meats and of the sufficiency of milk 
and vegetable diet for those engaged in active physical 



work are not satisfactorily proven, there is no doubt 
that overeating of meat is but too common, and the 
warning note sounded against this practice by Dr. Haig 
may well be heeded. 

The Principles of Bacteriology. A Practical Man- 
ual for Students and Physicians. By A. C. Abbott, 
M.D., Professor of Hygiene, and Director of the Labor- 
atory of Hygiene, University of Pennsylvania. Fifth 
edition, enlarged and thoroughly revised. Philadelphia 
and New York: Lea Brothers & Co., 1899. 
In the present edition of Abbott's well known and 
popular bacteriology, the subject matter has been brought 
well up to date, and the book is now one of nearly 600 
pages. The work is designed for the use of students, 
and the author has admirably accomplished his purpose. 
We know of no other manual on this subject that so ade- 
quately fulfils its mission, and in which more painstaking 
care is given to all the minor details so important to every 
student, and so frequently omitted from the text-books. 
We still, however, must take exception to the limited 
index, and trust that a future edition will be more com- 
plete in this matter. Many new illustrations have been 
added and the work is a beautiful example of modern 
bookmaking. 



THERAPEUTIC HINTS. 



To Remove Odor of Iodoform. — If after washing the hands 
well with soap and water a teaspoonful of vinegar be 
rubbed over them the unpleasant odor of the iodoform 
will be overcome. — Ricketts. 

For Infantile Angina. — 

R Ac. carbolici . . . . gr. xv 

Glycerini . . . . . 3 iss 

01. thymi ..... gtt. ii 

Aquae ...... Oi. 

M. Sig. For irrigation of pharynx. 

Powder for Vulvar Pruritus. — For non-parasitic form : 

R Hydrarg. chlor. mit. . . . gr. viii 

Pulv. belladonuEe . . . gr. iii 

Potassii brom. ) 

Bismuth subnitrat. ^ ^a . . gr. xv 

Pulv. amyli . . . . 3 v. 

M. Sig. External use. — Mussy. 

For Hoarseness in Singers and Speakers. — 

1. R Cocain hydrochlorat. . . gr. xv 

Strychninae sulphat. . . . gr. ^ 
Aq. dest. ..... 3 iii. 

M. Sig. For spraying throat. 

2. R Cocain hydrochlorat. . . . gr. ^ 

Tinct. aconiti . . . . ;«. x 

Altheas ) 

Sacchari alb. f ^a . . . q. s. 

M. Ft. pastilli No. L.XXX. Sig. Dissolve in mouth. 
—BoUj: 



THE MEDICAL NEWS 

A WEEKLY JOURNAL OF MEDICAL SCIENCE. 



Vol. LXXV. 



New York, Saturday, July 8, 1899. 



No. 



ORIGINAL ARTICLES. 



BICYCLING IN ITS REHTION TO HEART 
DISEASE* 

By a. C. GETCHELL, M.D., 

OF WORCESTER. MASS. 

It has been shown, particularly by Allbutt ' and 
Da Costa,' that continued work at laborious avoca- 
tions and continuous activity of a milder sort, such 
as long marches of soldiers, may produce not only 
functional disorder of the heart, but actual disease 
of the heart and bloodvessels as well. I propose 
in this paper to discuss the effect of another kind of 
continued muscular exertion on the heart, namely, 
bicycling. In the consideration of the subject I 
shall divide the riders into two classes, the untrained 
and the trained. First the untrained. Under this 
class I include those who are learning to ride and 
those who ride for pleasure or business only, in con- 
tradistinction to the athletic amateur or professional 
rider. 

The accident that these riders are most liable to 
is dilatation of the heart, and particularly of the 
right heart, which may be permanent or may last for 
but ashort time. Acute dilatation happens in this wise: 
Under the stress of prolonged and severe muscular 
activity the demand for pure blood in the tissues is 
greatly increased. This is met at first by more rapid 
breathing and accelerated heart action. But if the 
demand be too long continued or through special 
causes, like rapid hill climbing, be too greatly in- 
creased, the right heart cannot send the blood 
rapidly enough through the lungs. Some remains 
in the right ventricle at the end of each contrac- 
tion. This amount increases with each cardiac 
cycle and the cavity is stretched. The rider is now 
out of breath. If the task he has set out to accomplish 
is too great, and if he persists the dilated ventricle 
fails to act, and unconsciousness ensues. Through 
the cessation of bodily action the heart is relieved 
of its burden and resumes its function if it have suf- 
ficient vitality. On the other hand, if it be dis- 
eased death may ensue. 

The following cases are examples of this accident, 
and they illustrate different conditions under which 
it may happen; HerschelP was riding with a friend 
who was new to the wheel. After pushing up a long 

♦Read at the sixteenth annual raeetinp of the American Climato- 
logical Association, held at New York, May 9. 10, and 11, 1S99. 



hill he noticed that his companion was much ex- 
hausted, that his face was pale and his lips blue. 
He was obliged to dismount and lie upon his back 
on the grass. Examination showed marked dilata- 
tion of the right heart, feeble impulse, and rapid 
pulse. After an hour he was able to resume his 
journey, and in the evening the heart was normal. 

A patient, of mine had a similar experience. He 
was riding with his sister, and at the summit of a 
long and gradual ascent reached out to help his 
companion by pushing her over the crest, when he 
fell from his wheel unconscious. He soon recov- 
ered, and after a time proceeded on his ride. This 
man was about thirty- five years of age, and had rid- 
den the bicycle for several years. Of late years his 
health had been very good, though he suffered some- 
what from dyspepsia. As a child, however, he was 
delicate. His father died of heart disease. I have 
never had an opportunity to make a satisfactory ex- 
amination ot his heart. Once, however, I had oc- 
casion to spray into his nose for the purpose of an 
e.xamination a four-per cent, solution of cocain. 
Pronounced and distressing cardiac symptoms im- 
mediately ensued, which lasted to a greater or less 
degree for several hours. At this time I made a 
superficial examination, but detected no lesion. 

A retired wine merchant, while riding overa level 
road at a moderate pace fell from his wheel and 
soon died. Autopsy showed rupture of a heart dis- 
eased with fatty degeneration, and also a stomach 
full of an undigested meal.' 

These are instances of acute dilatation occurring, 
first in healthy persons who are subjecting them- 
selves to severe exercise, when, as the horsemen 
would say, they are "soft;" secondly, of those who 
are inured to the e.xercise, but who have weak 
hearts, and, thirdly, of those whose hearts are 
actually diseased. 

It is well recognized that dilatation of the heart 
occurs in the course of severe illness, and particu- 
larly when there is marked febrile movement. Un- 
der these conditions there are two factors to be 
considered in its production: First, the integrity of 
the heart- muscle, and, second, the resistance to be 
overcome. In disease the nutrition of the heart may 
suffer more or less, according to the amount of toxic 
products which are circulating in the blood. There 
mav be obstacles to the blood current, as, for in- 
stance, a consolidated lung. 



34 



BICYCLING IN ITS RELATION TO HEART DISEASE. 



[Medical News 



The problem is not so clear in the question of 
dilatation from severe muscular exertion in the well. 
At first sight it would seem that neither of these 
factors is present, because physiologically increased 
activity of the body in the open air would seem to 
purify the blood, and increased muscular exertion 
would send it more freely through the tissues. This 
is true up to a certain limit, and that limit depends 
upon the relation of two factors, the amount of 
work to be done, and the ability of the organism to 
do it. To quote Gibson: * "There is one consider- 
ation (in the production of dilatation) that must 
not be overlooked. While the effect of stimulating 
a muscle in experiaiental physiology is to accelerate 
the flow of blood through it, the effect of long-con- 
tinued muscular action must be to form a large num- 
ber of waste products, and it will necessarily follow 
that the blood may have greater difficulty in passing 
through the tissues after it has been loaded with 
such substances. The mere muscular exertion, more- 
over, invohed in long-continued efforts is to in- 
crease intrathoracic pressure, and this, added to the 
greater impurity of the blood, will interfere with 
the functions of the right side of the heart." 

In bicycling a proof of the existence of toxic 
matters in the blood is found in the so-called 
fatigue fever, which is produced by the absorption 
of toxins into the blood. In its milder forms it is 
not uncommon. A personal experience furnishes a 
good example. One hot day last August with a 
party I rode over a hilly road to the foot of a small 
mountain, ascended the mountain, and returned 
home. The trip occupied the entire day, from 9 
A.M. to 5 P.M., with a short rest at the top of the 
mountain. I was on a tandem bicycle, accom- 
panied on the ride out by a child of ten, and on the 
return by a lady. I was not jiarticularly tired on 
my return. During the night, however, I became 
very restless and could not sleep. My pulse was 
rapid though regular, and I felt very hot. The ex- 
perience was so novel, and to me then unaccount- 
able, that I could explain it only on the supposition 
that I was coming down with some acute illness. 
Alter a very uncomfortable night and an unsuccess- 
ful attempt to breakfast, I remained in bed during 
the entire day. I was not a novice at the wheel, 
having ridden a good deal for ten years. In some 
instances there is much more cardiac disturbance, 
and an irritable condition of the heart persists for 
several days. 

The second factor in the production of permanent 
dilatation of the heart is increased peripheral re- 
sistance. This ensues in part as a consequence of 
the accumulation of toxic products in the blood 
and in part in the stasis that occurs in the lung 



owing to the inadequate action of the right heart. 
Add to these causes the occasional severe strain of 
spurting and rapid hill climbing and the crouching 
attitude of the scorcher, and we have causes ade- 
quate for much trouble. It thus appears that bi- 
cycling may furnish the two conditions for the pro- 
duction of permanent dilatation of the heart, 
namely, toxins in the blood and increased per- 
ipheral resistance. 

Dilatation is not the only evil to be feared. \'al- 
vular disease may result as well. The auriculo- 
ventricular orifices undergo changes in dilatation of 
the cavities, and thus their dimensions are con- 
siderably increased. As a consequence of this the 
cusps of the valves do not meet as perfectly as in 
health. In acute illness a murmur, which later dis- 
pears, may be heard at these orifices. Under these 
conditions both the muscular walls and the auriculo- 
ventricular ring have not stretched beyond the lim- 
its of a possible return to the normal condition. 
Even if a ventricle weakened by disease has become 
dilated it is possible by rest and proper treatment 
to bring about either a restoration to the normal 
condition or a compensatory hypertrophy. It is 
doubtful if such a process is possible to an over- 
distended auriculoventricular ring, and as the 
cusps remain the same size a permanent disability 
of the valve must follow. 

Let us now consider the effect of the exercise 
upon the trained rider. The claim is put forth that 
there can be no danger to men, and indeed women, 
of this class, since they never are distressed by 
their exertions. But an examination into the con- 
ditions shows that this reasoning does not hold 
good. 

Hypertrophy of the heart as the result of con- 
tinued and severe muscular effort is regarded as 
physiological. Thus the hearts of race horses and 
greyhounds are found to be greatly hypertrophied. 
Moreover, teachers of gymnastics tell us that the 
best results in the development of the peripheral 
muscles are attained by continued exercise against 
slight resistance rather than vigorous action against 
great resistance. According to Gibson, a prominent 
feature in the production of pathological hyper- 
trophy of the heart is its rapid action. Da Costa 
found hypertrophy to result from the irritable con- 
dition which he described in soldiers. Osier says 
that the condition (/. e., irritable heart) is not in- 
frequent in civil life among young men, and it leads 
in some cases to hypertrophy of the heart. Herschell 
is of the opinion that hypertrophy may result from 
long-continued palpitation. 

We have seen that one of the characteristic 
features of fatigue fever from bicycling is longcon- 



July S, 1899] 



BICYCLING IN ITS RELATION TO HEART DISEASE. 



35 



tinued acceleration of the pulse. This acceleration 
also occurs without any fever or uncomfortable sen- 
sations. It has been found by a number of experi- 
ments with different classes of riders — men, boys, 
and girls — riding over roads of different grades and 
against head winds, that after riding at a certain 
rate, the pulse being counted, if the speed be in 
creased the pulse rate increases in greater ratio, and 
that too with the rider feeling no sense of fatigue. 
Thus the pulse-rate was found to increase from a 
normal of 72, 74, 80, and 84 to 112, 130, and 140, 
and in some instances this increased rate was main- 
tained for several hours. 

Riders of this class do not suffer from the ac- 
cumulation of toxic substances in the blood as do 
their less vigorous companions, and the blood, is 
sent through the tissues with greater freedom. But 
still there is a certain amount of resistance to be 
overcome, and when we add to these two factors, 
namely, long continued, rapid movement and slight 
peripheral resistance, a third, good nutrition which 
is the result of bodily well-being produced by train- 
ing in the open air, it is readily seen that we have 
the conditions most favorable to the production of 
cardiac hypertrophy. This does not mean that all 
trained bicycle riders suffer from hypertrophied 
hearts, medically speaking, because their training 
and life enable them to maintain the nutrition of 
the heart as well as that of the body at such a state 
as to fully compensate any alteration of structure. 
It is said, however, that athletes are liable to rapid 
deterioration of health when they relinquish their 
active exercises.* 

What is the effect of such overexertion on the 
blood-vessels? As Allbutt has well said, the muscu- 
lar ventricle may grow both in size of its cavity and 
in the thickness of its walls, but the walls of the 
aorta suffer under greater limitations ; its power of 
resistance is great, but its activity is nothing more 
than the rscoil of elastic fibers. Such repeated 
stretching results not in increased strength, but 
rather in weakness, as one of the coats may give 
way and pouching result, or an endaortitis ensue, 
or indeed incompetence of the aortic valves follow. 

Lannois " reports a case of rupture of one of the 
aortic cusps. It occurred in a man, aged thirty- 
eight years, during a ride from Paris to Madrid, a 
distance of 1452 kilometers, in nine days. There 
was not at any time pain or other evidence of the 
accident, nor was his health impaired, and the 
lesion was discovered some time later rather by ac- 
cident. 

To summarize; Acute dilatation of the heart is an 
accident that may be expected from overexertion 
in an unathletic rider, and if the conditions be re- 



peated permanent dilatation, especially of the right 
heart, may result with a consequent damage to the 
auriculoventricular valves. And, secondly, in the 
athletic hypertrophy may be produced with a possi- 
ble consequence of disease of the aorta and incom- 
petence of the aortic valve. 

In discussing the application of these principles 
I shall consider three classes of riders: First, young 
children; second, young adults; third, persons ap- 
proaching middle life and the unhealthy. Fortu- 
nately, in the past the price of a bicycle has pre- 
cluded its use as a mere toy, and very young riders 
have been comparatively few. Still one sees them 
not only in the parks and streets, but in the country 
as well far from home. I can see no justification 
whatever for this practice. Boys and girls under 
thirteen or fourteen should not be allowed to take 
rides into the country where they may get far from 
home, and be subject to unwise exertion of a long 
ride or immoderate hill climbing. I doubt, too, 
the wisdom of allowing a young child to ride ad 
libitum even in the park or on asphalted streets. 
The sport is fascinating and not fatiguing, and it is 
not an uncommon experience to see young children 
riding hour after hour. Even on a level space, as 
we have seen, and entirely within the range of non- 
fatigue, the heart's action may be accelerated, and 
this increased activity may persist long after the 
riding is over for the day. Nor does the child es- 
cape more serious consequences, as this incident, 
which occurred in my neighborhood, shows: The 
child was a girl of twelve, previously fairly healthy. 
It had been noticed, however, that she got out of 
breath easily while riding. One afternoon she went 
into the country, which was rather hilly, with 
friends for a ride. Nothing unusual was noticed ex- 
cept that she was somewhat out of breath going up 
hills. She took tea with a friend, and after the 
meal again rode about the square, this place being 
slightly hilly also. On going to bed she had some 
gastric distress, and the fainily physician was called. 
He regarded the symptoms as due to indigestion, 
and prescribed accordingly. The child's room ad- 
joined that of her mother. The latter was wakened 
in the night by her daughter's distressed breathing. 
Before help could be called the child died. Tkere 
was no autopsy, but it is apparent that death was 
due to acute dilatation of an unhealthy heart pressed 
upon by a distended stomach. 

In the second class of cases, healthy young adults, 
there is need of precaution against excessive hill 
climbing and very rapid riding, as the following 
cases show: C. F., aged twenty years, employed in 
a sewing-machine factory, consulted me for relief of 
a frothy expectoration. His family and personal his- 



36 



BICYCLING IN ITS RELATION TO HEART DISEASE. 



[Medical News 



tory was good. He had been a bicycle athlete, and 
had ridden in many races. His early symptoms were 
cough, a feeling of substernal oppression, and un- 
comfortable sensations referred to the cardiac area. 
He stopped riding and grew better, to resume it 
after a winter, only to be obliged to discontinue it 
altogether. His throat and lungs were without evi- 
dence of disease. The impulse of the heart, which 
was feeble, was felt in the sixth interspace just in- 
side the nipple line. The sounds were fairly pure 
in character, but faint over ihe tricuspid area, 
while over the aortic and pulmonic areas the first 
sound could not be heard at all. In this instance 
there was dilatation following hypertrophy. 

In the following case the opposite conditions pre- 
vailed, first dilatation, then hypertrophy: H. B. , 
aged twenty si.\ years. Before the age of twenty he 
had always been well. Then he began to ride the 
bicycle. He lived in a very hilly town, was a 
scorcher, rode a wheel with eighty gear, and never 
got off for a hill. Presently he found himself un- 
able to ride, and for some time after giving up the 
wheel was not in good health, having frequent 
fainting spells. He gradually grew better, and re- 
sumed riding but in moderation. His heart pre- 
sented these features when I examined him five 
years after his illness : The apex-beat was appar- 
ently to the right of and below the ensiform appen- 
dix, really the impulse of a hypertrophied right 
ventricle. There was decided pulsation over the 
lower right portion of the sternum. Duluess ex- 
tended one and one-half inches to the right of the 
median line and three inches to the left at the level 
of the fourth rib. The first sound over the epigas- 
trium was impure. The pulse was 120 and regular. 
The rapid pulse was due to the excitement of the 
examination. He said it was usually 72. But this 
acceleration showed that the heart was irritable. 

In this connection it would be interesting to 
learn the experience of the surgeons who examined 
recruits for the army in the lale war. I have been 
able to find but one. In an article in the Medical 
Standard, detailing the results of the physical exam- 
ination of 9901 officers and men of the Illinois 
National Guard, Lieutenant-Colonel Charles Adams, 
speaking of the heart, says: "In the preliminary 
examination of recruits made by medical officers of 
different regiments before leaving their home sta- 
tions many cases of bicycle heart were discovered 
and the men not allowed to enlist. These were 
characterized by hypertrophy and dislocation of 
the apex-beat, with irregular or rapid beat."' 

Da Costa's tables show that fully two-thirds of 
his cases happened from the sixteenth to the twenty- 
fifth year, while the great percentage was from the 



twentieth to the twenty-fifth. These figures are 
fairly reliable for our present purposes, because our 
army was recruited from men of the same class as 
our bicycle army. Men then, and women also, who 
take to the wheel between the ages of twenty- five 
and thirty-five, if healihy, are little liable to 
trouble because their physical powers are matured, 
and also because as a class they are not apt to in- 
dulge in the excesses of the more youthful. 

From the age of forty, however, conditions are 
likely to be different. Those who begin to ride at 
this time in their life are the man of leisure or the 
bookkeeper or clerk, people who have spent the 
greater part of their life indoors, have very probably 
been high livers, and as a consequence suffer from faulty 
nutrition. To such the bicycle may be a blessing 
or a positive danger. Proper regard for hills, ex- 
cessive exercise against high winds, rough roads, 
and the gear of the wheel will make the exercise 
beneficial, while one indiscreet overexertion may 
cause irreparable injury. 

And, lastly, those who seek medical advice for 
ill health, such as dyspepsia. In all such cases be- 
fore advising the use of the bicycle the heart should 
be carefully examined, for it must be remembered 
that the symptoms for which the patient seeks relief 
may derive their origin from some disorder of the 
heart or blood-vessels. Indeed, instances are on 
record of persons by bicycling, at first getting 
much relief from their dyspeptic or gouty symp- 
toms, only later to fall victims to fatal disease of 
the heart. Under these conditions an examination 
of the heart should be exhaustive by the use of 
every means at our disposal — palpation, percussion, 
mensuration, and auscultation. The slightest devia- 
tion from the normal condition, whether it be in the 
character of the sounds, the relative intensity of the 
first and second sound in any area, their relative in- 
tensity in different areas, the rhythm of the heart, 
the character of the impulse, the condition of the 
arteries should be carefully noted, for it may be the 
heart that presents no gross lesion is the dangerous 
one, and the one that soonest breaks down under a 
severe strain. 

Even if cardiac or circulatory lesions are found it 
does not follow that the bicycle should be for- 
bidden, but it must be prescribed. Definite regula- 
tions must be laid down as to the character of the 
road, the length of periods of exercise, the kind of 
wheel, and the size of the gear. From personal ex- 
perience I feel sure that proper bicycle riding will 
materially strengthen a weak heart, as it undoubtedly 
improves the general nutrition of the body. My 
contention is not that bicycling is a harmful mode 
of exercise. Indeed, I hold to the opposite view very 



JULV 8, iSggJ 



THE PROGNOSIS OF PNEUMONIA. 



strongly. Bicycling is productive of great good, 
both in the way of health and of pleasure. But at 
the same time we must recognize the fact that it 
presents peculiar temptations to excessive exertion 
that is dangerous. 

The athlete will probably go his way without ask- 
ing or taking our advice. But we should be in a 
position to influence the youth in our midst, and 
especially those who seek medical advice If the 
bicycle is prescribed as a therapeutic agent for any 
trouble including disease of the heart it must be 
carefully prescribed, and not merely recommended, 
leaving the patient to his own inclinations and 
possible indiscretions. 

BlBLIOGR.^PHV. 

' Allbutt, "The Effects of Overwork and Strain on the Heart 
and Great Blood-Vessels."' 6"/. George Hosp. Rep., vol. v, p. 23. 

2 Da Costa, "Irritable Heart," Amer. Jour. Med. Sciences, 
vol. Ix-xi, p. 17. 

3 Herschell, "Cycling as a Cause of Heart Disease," London. 
i8g8. 

< Gibson, "Diseases of the Heart and Aorta," 1S98. 

* Osier, "Practice of Medicine." 1S92. 

* Herschell, "Cycling as a Cause of Heart Disease." Lancet, 
i, p. 541, 1895. 

' Lannois, "Insuffisance aortique par rupture valvulaire chez un 
bicycliste," Bull, et Mem. Soc, Med. d. Hop. de Paris, 3. s. 
xiii, 852. 853, i8g6. 

'^ Medical Record, vol. liv. p. 274. 



r//£ PROGNOSIS OF PNEUMONIA IN ITS RE- 
L A T/ON TO ITS ETIOLOGY.- 
Bv HERBERT MAXON' KING, .M.D., 

OF GRAND RAPIDS, MICH. 

The clinical picture presenting in acute lobar 
pneumonia is so constant in its essential features, 
while its pathology is so comparatively undeviating, 
that a single well-defined case may be taken as a 
type from which variations are few and unimportant. 
Its pathologic aspect is clear, well defined, and char- 
acteristic, and in that sense pneumonia is always 
one and the same disease, whether primary or sec- 
ondary, mild or severe, and whether terminating by 
crisis or lysis, recovery or death. For this reason I 
think we have come to base the prognosis too much 
upon the physical condition and environment of the 
patient and too little upon the etiology of the dis- 
ease, which, it is scarcely necessary to demonstrate, 
is by no means always one and the same. 

Pneumonia is a term applied to a pathologic con- 
dition, the chief and characteristic lesion of which 
is found in the lung. It was employed to denote an 
acute lobar consolidation before the bacterial origin 
of such a condition was discovered, and it is, un- 
fortunately, still employed indiscriminately to de- 
scribe a pathologic process which, however uniform 

' Read before the Michigan State .Medical Society at Kalamazoo, 
Mich., May 4, 1899. 



its morbid anatomy, is not at all so in its causa- 
tive factors. It is time, therefore, it seems to me, 
in the light of present knowledge, that we cease to 
apply this term to all acute lobar consolidations; or, 
better still, that we, continuing to use the term 
purely with reference to its characteristic anatomic 
lesion, shall in every case modify it by a proper 
adjective to denote the true nature of the disease 
process as relates to its etiology. In other words, 
that we shall name each pneumonia for its ultimate 
causative factor so far as it is possible. As, for in- 
stance, "pneumococcic" pneumonia, "streptococ- 
cic" pneumonia, "influenza" pneumonia, etc. I 
maintain that it is just as unwarrantable to neglect 
the exact determination of this feature in pneumonia 
as it would be in a case of suspected phthisis. In 
deed, the steps necessary to be taken for this end 
are equally simple and very similar-in both phthisis 
and pneumonia. 

When this procedure shall have become a prac- 
tice the prognosis in lobar pneumonias will cease, to 
a very large extent, to be based upon "personal 
equation," and we shall bs eminently better quali- 
fied to estimate upon the probable course and out- 
come of the disease. Moreover, the knowledge thus 
added at the outstart will, no doubt, simplify and 
make more exact the treatment of the individual 
case. Vital statistics, when compiled with this 
feature in view, will have much more meaning, and 
for their practical application" they will possess a 
much greater value to the sanitarian. 

It is my object here, however, simply to point out 
the importance of ascertaining the nature of a pneu- 
monia with relation to its etiology for the purpose 
of more accurately prognosticating the issue in any 
given case. To illustrate this point, permit me to 
cite briefly from my records of several typical cases 
among those which have come under my observation 
since having had this feature in mind. 

Case I. — Male, between fifty and sixty years of 
age, farmer by occupation. The history of the at- 
tack was typical. After a hard day's work, during 
which the patient felt as well as ever, he was sud- 
denly taken with a severe rigor, followed by fever 
and attended by sharp pain in the right chest; a dry 
cough, followed by "brick dust" expectoration in 
due time, great prostration, and at times a low de- 
lirium. Toward the end of the second week his 
temperature became remittent, with afternoon exac- 
erbations and occasional sweating. 

I saw the case in consultation early in the fourth 
week in the afternoon. The patient's temperature 
was 103' F.; pulse, iio. There was complete dul- 
ness over the lower right lobe, less marked over the 
middle lobe, and quite perceptible over the left 
lower lobe. Vesicular murmur was lost in the mid- 
dle, right and lower portion of the lower left lobes. 



38 



THE PROGNOSIS OF PNEUMONIA. 



[Medical News 



and no respiratory sounds whatever were to be heard 
over the lower right lobe. Expectoration was pro- 
fuse and of a dirty brick-dust color. The urine was 
non-albuminous, responding negatively to Ehrlich's 
diazo-test. 

Microscopic examination of the sputum demon- 
strated the presence in enormous number of the 
pneumococcus of Fraenkl, with practically no other 
micro organisms. (This was rather unexpected in 
view of the remittent character of the temperature 
and the sweating, which suggested sepsis.) The 
diagnosis, based upon the findings, was acute 
pneumococcic lobar pneumonia, and the prognosis 
was very favorable for complete recovery, provided 
a secondary streptococcic or other pyogenic infection 
did not occur. 

If seen early in the course of the disease such a 
prognosis could not safely have been made, for it is 
in these pneumonias that death on the eighth to 
twelfth day from acute toxemia occurs, but, having 
survived the first shock, the outlook for recovery was 
favorable. I have since learned that convalescence 
was slow but uneventful and complete. 

C.4SE II. — This case was under my own observa- 
tion from the first, so that I had an excellent oppor- 
tunity for complete investigation: Female, twenty- 
eight years old, had been under observation and 
treatment for pulmonary tuberculosis involving the 
left apex for two months prior to the onset of the 
pneumonia. She was feeling ordinarily well and 
was able to attend to her usual occupations. After 
two days of slight indisposition and moderate eleva- 
tion of temperature a sharp rigor and rise in temper- 
ature to 105° F. occurred. Pain in the left chest, 
dyspnea, and prostration marked the onset of an 
acute lobar pneumonia, involving the whole of the 
left lung. Consolidation was the most complete I 
have ever seen. There was absolutely no respiratory 
sound except a bronchial tubular breathing, which 
came to the ear with a metallic, almost musical, 
sound. Cough and expectoration were entirely sus- 
pended. Exploratory aspiration failed to show fluid 
in the pleura or lung. Cyanosis of the lips and nails 
was marked. Passing over irrelevant details of the 
case the crisis occurred on the thirteenth day, with 
distinct improvement in subjective symptoms follow- 
ing immediately, and a return to some extent of 
the cough, which had been absent since the initial 
chill. Expectoration was, however, very scant. A 
glairy mucus by microscopical e.xamination was 
shown to contain tubercle bacilli in "clumps" re- 
sembling pure cultures in arrangement, but there 
were no other micro-organisms. Within a few days 
the expectoration became mucopurulent and the 
tubercle bacilli gradually lost this peculiar arrange- 
ment, but were the only organisms found in the ex- 
pectorated matter. 

It is of interest to note that prior to the pneu- 
monia cough was a persistent symptom. Expectora- 
tion was much more profuse and more purulent in 



character, while the bacilli were more scattered 
throughout the specimen. With the supervention 
of the typical pneumonia I was prepared to find a 
secondary pneumococcic infection, but as soon as 
expectoration was procurable the diagnosis of acute 
tubercular lobar pneumonia was made and a prog- 
nosis favorable, so for at least as recovery from the 
pneumonia was concerned, was allowed. It is in 
such a pneumonia as this, however, whether preceded 
by evidence of pulmonary tuberculosis or not, that 
hydrothorax is apt to occur as a complication, and, 
indeed, a serous effusion into the pleural cavity oc- 
curring in the course of a pneumonia may be taken 
as proof positive of the tubercular nature of the 
pneumonia just as purulent effusion in the course of 
pneumonia may be taken as evidence that the pneu- 
monia is due, if not entirely, at least in part, to in- 
fection by pyogenic organisms. 

In the case in point resolution proceeded slowly 
but uninterruptedly and the lung cleared up, leaving 
the patient no worse off than she was before the 
pneumonia. Subsequently, however, a serous ef- 
fusion into the pleural cavity occurred and about 
three pints of fluid was aspirated. 

C.\SE III. — Female, about thirty eight years old. 
A protracted, difficult placenta-previa labor was fol- 
lowed, at some interval, during which septic fever 
occurred (the history obtained was indefinite and 
vague), by phlebitis, and ten days after labor by the 
initial symptoms of acute lobar pneumonia, involv- 
ing the two lower lobes of the right lung. This 
pneumonia ran an irregular course for three weeks, 
when abscess and necrotic changes became evident 
and I saw the patient for the first time. The breath 
was horribly foul, and expectorated matter con- 
tained shreds of broken-down lung tissue, pus, and 
the usual abscess detritus. The chief micro organ- 
ism found besides the saprophytes, always present in 
such conditions, was the streptococcus pyogenes in 
chains of from ten to thirty elements. There were 
no pneumococci, influenza, or tubercle bacilli. The 
case was, therefore, one of acute streptococcic lobar 
pneumonia, probably originating in a septic thrombus 
from the involved veins in the extremities. The 
prognosis, when I saw the patient, was favorable for 
recovery, without serious complications or sequela. 

Had a bacteriologic examination been made be- 
fore the formation of abscess I have no doubt strep- 
tococci would have been the prevailing organism 
found. The prognosis then could have been made 
with fair degree of certainty as follows: Favorable 
for eventual recovery, with the probabilities, how- 
ever, in favor of abscess or empyema as complica- 
tions, and more or less impairment of the lung as a 
result. 

Of course, necrotic changes occurring in the 
course of streptococcic pneumonia cannot ordinarily 
be foreseen. Gangrene, rupture of a pus-sac into • 



July 8, 1899] 



THE PROGNOSIS OF PNEUMONIA. 



39 



the pericardium or peritoneum, etc., must be re- 
garded as accidents which cannot fairly enter into 
consideration in the prognosis of such cases. In 
the case in point, however, originating as it did pre- 
' sumably from a thrombus, necrosis was to be ex- 
pected. This patient lived up to my expectations, 
and is at present quite well, although convalescence, 
as might have been expected, was tedious. 

Case IV. — The last case which I shall cite in il- 
lustration is also one in which I have enjoyed ex- 
cellent opportunity for study: Female, between fifty 
and sixty years of age, appeared with symptoms of 
a bad "cold," congestive rhinitis, dry cough, pain 
in the head, back, and legs, some rise of tempera- 
ture and pulse rate, with slight rigors. For two or 
three days these symptoms continued, the fever in- 
creasing with great prostration, and on the fourth 
day a more severe chill with temperature of 103.5° 
F. was followed by the appearance of physical signs 
of lobar pneumonia involving the lower lobes of 
both lungs. The cough, which had been dry and 
persistent heretofore, now became productive of a 
mucopurulent expectoration which contained Pfeif- 
fer's bacillus of influenza in great abundance; there 
were no other micro-organisms in sufficient number 
to be characteristic, and no pneumococci at all. 

The diagnosis thus established at the very start 
was acute influenzal lobar pneumonia, and the prog- 
nosis was of necessity guarded, but on the whole 
favorable. The case pursued an irregular course, 
uncomplicated by other infections. Consolidation 
gradually disappeared, there was no crisis, and a 
tedious and protracted convalescence left the pa- 
tient in a deplorable nervous condition. 

There was no pleuritis during the course of this 
pneumonia, and of course no tendency to effusion; 
indeed, I have never seen the pleura affected in un- 
complicated influenza, and do not believe such com- 
plications ever arise without other infection than 
that by Pfeiffer's bacillus. This is a broad state- 
ment, but one which I think will be borne out by 
observation. Many cases of pleuropneumonia, so- 
• called pleuritis, dry and with effusion, are reported 
as "grip" complications, but so far as my experi- 
ence or information goes these complications arise 
from multiple infections, made more easy, no 
doubt, by the depletion of the system by true influ- 
enza toxemia, but never directly due to Pfeiffer's 
bacillus, which we must admit as the sole origin of 
this peculiar toxemia. 

In these illustrations I am aware that some objec- 
tion is reasonable on the ground that such single in- 
fections are not the rule and that the great majority 
of pneumonias not dependent upon the pneumococ- 
cus are multiple infections. Moreover, many pneu- 
mococcus pneumonias, especially those running an 
irregular course, are no doubt cases in which from the 
start or sometime subsequent to the initial chill there 



is infection by more than one organism, but I have 
purposely chosen these cases of single infection to 
better illustrate the point, and while any pneumonia 
may present in a sputum examination several varie- 
ties of pathogenic organisms, there will always be 
found a predominating, and so to speak, primary germ, 
upon the natural parasitic history and pathogenic 
properties of which will to a very large extent de- 
pend the prognosis of the disease. The cases cited, 
then, are typical, and will, I think, be found safe 
guides so far as they go. There are, no doubt, 
pneumonias which do not fall into any of the classes 
mentioned. Further study with this idea in view by 
many observers will be necessary not only to make 
prognosis in such cases a more definite matter but to 
place a clinical value upon my own experience and 
corroborate or falsify my conclusions. 

First, then, in conclusion, a pneumococcus pneu- 
monia occurring in a previously healthy individual 
under sixty-five years of age tends to recovery by 
crisis, runs a distinct and definite course, is not 
complicated by pleural effusions, and, in patients 
who recover, does not permanently affect the in- 
tegrity of the lung or cause abscess or gangrene. 
On the other hand, it furnishes by far the greatest 
pneumonia mortality; and death in the fatal cases is 
due to acute toxemia. 

Second, tubercular pneumonia, occurring either 
as the initial stage of pulmonary tuberculosis, or in 
the course of the latter disease, runs an acute and 
oftentimes alarming course, is more irregular in its 
development, may terminate by crisis as distinct as 
that in pneumococcus pneumonia or by gradual sub- 
sidence, is not attended hy suppuration, either in the 
lung or pleura, may, however, produce pleuritis, 
dry or with profuse serous effusion, is seldom, if 
ever, immediately fatal, and it is doubtful if its re- 
mote results upon the general tuberculous process 
are harmful. 

Third, streptococcic pneumonia (including all 
pneumonias dependent upon infection by pyogenic 
organisms) forms a very large proportion of all pneu- 
monias, runs a very irregular, prolonged and atypical 
course; is always the class in which empyema, ab- 
scess, or gangrene of the lung is to be feared; is the 
pneumonia in which septic complications in other 
organs are to be looked for, and in case of recovery 
of the patient, often more or less seriously impairs 
permanently the integrity of the lung or pleura. 

Fourth, influenza pneumonia, if uncomplicated, 
runs a shorter course, in which less-marked dis- 
turbance with the body temperature is associated 
with much greater disturbance of the vasomotor 
nervous system and with profound prostration, does 
not tend to terminate by crisis, does not involve the 



40 



INTENSITY OF THE HEART TONES. 



lMedical News 



pleura, nor of itself permanently affect the integrity 
of the lung, and is seldom of itself fatal. On the 
other hand, this class of pneumonias more than any 
other predispose the lung to infection by other 
pathogenic organisms, among the more frequent of 
which (probably because of their omnipresence) are 
the streptococcus and tubercle bacillus, consequently 
this pneumonia is, more than any other, subject to 
complications and sequels arising from multiple in- 
fections. 

When the bacteriologic examination relegates a 
pneumonia to its special class then a prognosis may 
be safely based upon such general principles as I 
have endeavored here to outline, guarded, of course, 
by the condition that it shall remain within its 
special class and subject to such modification as sub- 
sequent examination (which, it is needless to say, 
should be frequent) shall demand 

It must be remembered that while almost all pneu- 
monia sputum is likely to present many varieties of 
micro-organisms there will be one variety which will 
prevail in such predominance as to enable the phy- 
sician to classify the case and with the exercise of 
sound judgment prognosticate its issue with a fair 
degree of certainty. 

Finally I have purposely avoided citations from 
the prodigious amount of literature on the subject of 
prognosis in pneumonia; first, because in such a pa- 
per as this, to be read before a society, the chief ob- 
ject to serve is that of exciting a full discussion, an 
object which is too often defeated by tedious and 
unnecessary annotations and references, consuming 
time which could otherwise be given to discussion; 
and second, because in the literature to which I have 
access I have failed to find anything which takes up 
this subject trom the point of \ie\v which I have en- 
deavored to assume. 



MEASURING THE INTENSITY OF THE 

HEAR T TONES. 

By albert ABR\MS, M.D., 

OF SAN FRANCISCO. 

It has no doubt been a source of regret to many 
physicians who are habitually engaged in the exam- 
ination of the chest that we are in possession of no 
accurate means of registering the heart tones to 
facilitate accuracy in determining the progress of 
our patients with heart lesions, or the action of 
cardiac tonics. There are different factors which 
normally determine the loudness of the heart tones. 
One factor is the varying conductivity of the differ- 
ent structures in the chest wall and between the 
thoracic wall and the heart. The chief factor, how- 
ever, is the strength of the heart's action. Auscul- 
tation of the heart tones in the conventional man- 



ner not infrequently affords us no indication of- 
cardiac strength if reliance is to be placed on the 
intensity of the tones in their selective propagation 
to different parts of the chest. 

I have often been struck by the loudness of the 
heart tones in emaciated individuals in whom the 
action of the heart was found to be feeble, as de- 
termined by the sphygmomanometer and sphygmo- 
graph. In convalescents from typhoid fever the 
foregoing fact has been especially emphasized in not 
a few instances. In anemics we often hear very loud 
tones, even though the blood pressure is low, and 
again in dilatation of the stomach when that organ 
approximates the cardiac area, the tones by mere 
resonance are loud, even though the strength of the 
heart is reduced. In many emaciated persons it 
often happens that the heart tones are conveyed to 
the interscapular region, to the epigastrium, and 
even the head without any corresponding increase 
in the force of the heart. In such instances the 
thorax is practically a resonator. If then, in cer- 
tain instances, auscultation is no trustworthy index 
to the force of the heart, have we not in the sphyg- 
momanometer and sphygmograph clinical instru- 
ments of sufficient reliability to gage the blood 
pressure? Unfortunately, in the application of 
these instruments we must contend with the objec- 
tional personal equation and content ourselves with 
the determination of the blood pressure in the sys- 
temic circulation only. When the phonograph was 
first introduced I thought I saw in that instrument 
the consummation of my hopes, but after consider- 
able experimentation it proved useless. In my 
"Manual of Diagnosis" ' the results are expressed as 
follows: "In my investigations, which were varied 
in every manner possible, the recording of heart 
sounds was practically impossible. The fault rests 
with the phonograph. There is no question about 
the sensitiveness of the diaphragm for recording 
even the feeblest sounds, but the difficulty lies in* 
leproduction. Even loud sounds emanating from 
the chest are with difficulty detected by an ear ac- 
customed to the phonograph. When the repro- 
ducing needle is adjusted to the revolving wax 
cylinder a hissing sound is heard, the result of fric- 
tion between the needle and the wax. It is this 
sound which interferes with proper reproduction. 
If this objection were obviated the phonograph would 
prove an ideal instrument in physical diagnosis." 

The following method for measuring the heart tones 
is suggested for its simplicity. It is only relatively 
accurate. It is based on the simple physical prin- 
ciple that the intensity of sound varies inversely as 
the square of the distance from the sounding body, 

' "Manual of Clinical Diagnosis," third edition, 1894. 



JLLVS, 1899J 



INTENSITY OF THE HEART TONES. 



41 



hence the distance to which a heart sound may be 
heard depends upon its intensity, ignoring of course 
those adventitious causes of propitious conductivity. 
Between the area auscultated and the stethoscope a 
medium is interposed. Experiment has taught me 
that one of the best media is partially vulcanized 
rubber in the form of a rod, and just sufficiently 
soft as not to interfere with convenient manipula- 
tion. Such rods may be purchased in any store 
where rubber goods are sold. The circumference 
of the rods must equal the caliber of the pectoral 
end of the stethoscope in which they are to be in- 
serted. The degree of insertion must be regulated 
by a notch cut into the rubber. The object of this 
regulation is to insure uniformity of results in the 
examination of individual patients. The rods may 
be of different sizes, varying in length from 6 to 
26 centimeters, or even of greater length. Before 
auscultating the heart tones by this method, we 
must first mark on the chest the different points in 
the precordial region where the heart tones are 
heard with the maximum degree of intensity. Over 
each ostium we auscultate with the rod inserted into 
the end of the stethoscope, beginning with a rod of 
medium length and gradually increasing the length 
of the rod until one is attained through which the 
heart tones are no longer conducted. The tubes are 
numbered, and a record may be made in our case 
book after the following formula: 

— 6 

— 5 



Mitral, I. tone 
II. tone 
Aortic I. tone 
" II. tone 
Tricuspid I. tone 
II. tone 
Pulmonary I. tone 
II. tone 



—4 

— 5 

— 6 

—4 

—4 
—5 



According to the foregoing formula we conclude 
the following: That with a rod (No. 6) which is 26 
centimeters in length we may still be able to hear 
the following tones: Mitral systolic and tricuspid 
systolic tones. A similar interpretation may be de- 
duced from the other numbers. These figures 
possess no value for general application as the de- 
gree of transmission is dependent on the character 
of the stethoscope as well as the length of the rod 
employed. Each observer must cut his own rods of 
different lengths. With some kinds of stethoscopes 
the first mitral and tricuspid tones are still heard 
with rods fully 30 centimeters in length, whereas 
with other kinds a rod of half the length will no 
longer transmit the same tones. In some instances 
another method may be adopted. It is less reliable 
than the former method, especic^lly in thin persons, 
owing to the increased conductivity of the thoracic 
tissues. As before, one marks on the chest wall the 



different situations where the heart tones, corre- 
sponding to each ostium, are heard loudest, and 
then proceeds in different directions until the sounds 
are no longer audible. The distance to which the 
sounds are propagated is marked and measured. The 
directions in which the sounds are auscultated have 
been determined empirically as follows: 

Mitral Tones. — Auscultate along a line on a 
level with the ape.x-beat to the left axillary region. 

Tricuspid Tones. — Auscultate along a line ex- 
tending from the point of auscultation to the right 
axillary region. 

Aortic Tones. — Along a line on a level with the 
point of auscultation to the right axillary region. 

Ftilnwnic Tones. — From the point of auscultation 
to the left axillary region. The tricuspid and mi- 
tral tones are best conducted downward by the liver, 
but as a differentiation of the mitral and tricuspid 
tones over the hepatic region is impossible this di- 
rection cannot be employed. I will mention, par- 
enthetically, that the liver is an excellent conductor 
of the heart tones, and when they are no longer aud- 
ible by auscultation we can safely conclude that the 
lower border of the liver has been reached. 

The following conclusions may be formulated: 

1. The loudness of the heart tones may be 
measured by testing the distance to which they 
are transmitted from their clinical point of ausculta- 
tion. 

2. This may be determined by two methods. 
The first method consists of measuring the distance 
to which the heart tones are propagated along def- 
inite routes on the chest. The second method con- 
sists of introducing between the stethoscope and the 
chest wall a soft rubber rod of varying length, the 
tones gradually becoming less distinct as successive 
rods of increasing length are employed. 

3. Of the two methods the latter is by far the 
more accurate, although this by no means represents 
an ideal attainment. 

4. The employment of either method does away 
with memory in observing the progress of the 
strength of the heart in individual cases, and en- 
ables us to distinguish more easily any accentuation 
of the tones. 

5 . The order in which the tones can no longer 
be heard is as follows, beginning with the weakest 
tones: First aortic, first pulmonary, second tricus- 
pid, second mitral, second aortic, second pulmon- 
ary, first tricuspid, and first mitral tone. 

6. Until a universal stethoscope is employed we 
cannot hope to make the method of measuring the 
heart tones of general application, but must content 
ourselves with the application of the method to in- 
dividual cases. 



MEDICAL PROGRESS. 



[Medical News 



7. The first point beyond the hepatic region 
where the cardiac tones are no longer audible marks 
the lower border of the liver. 



CLINICAL MEMORANDUM. 



TETANUS TREATED BY ANTITETANUS SE- 
RUM; REPORT OF A CASE.' 

Bv T. E. TAYLOR, M.D., 

OF DENVER, COL.; 
PROFESSOR OF OBSTETRICS IN THE UNIVERSITY OF COLORADO; AT- 
TENDING OBSTETRICIAN TO THE COLORADO COTTAGE HOME, 
AND TO THE ARAPAHOE COUNTY HOSPITAL. 

The frigntful mortality attending tetanus when left to 
run its natural course, and the almost complete failure of 
the ordinary therapeutic measures to favorably influence 
the course of the disease, leads us to look with favor upon 
any new remedy which promises benefit. The demon- 
strated infectious nature of tetanus, and the accepted 
therapeutic efficacy of the antitoxic treatment of diph- 
theria, and in minor degree, the streptococcus infections, 
together with the successful immunization of animals 
against tetanus cultures by injections of antitetanus se- 
rum, give a rational basis for the trial of this product m 
cases of developed tetanus. The considerable number of 
recorded cases exhibits a diminished mortality; and as in 
many of the fatal cases the serum was used only after the 
disease had already continued several days we may hope 
for a greater improvement when it is used early. Such a 
favorable case I am able to report : 

Mrs. J., married, mother of two children, called on 
Dr. A. E. Grant to attend her on January 27, 1899. 
She gave a history of a long series of miscarriages and re- 
sulting uterine disorders, and stated that for several days 
she had been flowing excessively, and something had 
pasfed from her which was destroyed without examina- 
tion. She had missed one period, and she supposed her 
menstruation was so profuse for this reason. She stren- 
uously denied having in any way induced an abortion. 
On January 24th, three days before, she had experienced 
chilly sensations, and thought she had caught cold. 

As the hemorrhage was severe, and Dr. Grant had no 
gauze or cotton with him he tamponed the vagina with a 
clean cloth furnished by the patient, which was soaked in 
a solution of mercuric bichlorid. Next morning she com- 
plained of stiffness of the neck and jaws, not being able 
to separate her jaws more than half an inch. Alarmed 
by these symptoms. Dr. Grant proposed a consultation. 
We saw her soon after noon, when in addition to the diffi- 
culty In opening her jaws and stiffness of her neck, she 
complained of soreness in the thoracic muscles. The fa- 
cial muscles were not noticeably affected, though there was 
heightened reflex irritability. Her temperature was 
99. 5° F., and pulse 95. 

We agreed that a thorough curettage of the uterus 
and irrigation of Its cavity was indicated, and this was 
done, the uterus being Irrigated with a solution of bi- 
chlorid I to 4000, and the uterus and vagina packed with 

' Read before the Colorado State Medical Society, June 20, 
1899. 



iodoform gauze. She was then returned to bed and or- 
dered full doses of bromid and chloral (though nausea 
prevented much being administered), and 4 c.c. of Parke, 
Davis & Co. 's antitetanus serum was Injected under the 
skin of the abdomen. We saw the patient again together 
at noon on January 29lh, and found the stiffness of the 
neck and jaws nearly gone. She was given an additional 
injection of 6 c.c. of serum. The nausea still prevented 
the administration of much medicine by the mouth. The 
packing of the uterus and vagina was removed and an 
antiseptic vaginal douche given. On the following day 
the stiffness of the muscles had entirely disappeared and 
the patient made an uninterrupted recovery. 

This termination of such a grave disease is as unusual 
as it is gratifying. Indeed, it is so very unusual that it 
compels a close scrutiny of the diagnosis, for of all the 
forms of tetanus that following an abortion Is perhaps the 
most hopeless. Gowers says that recovery Is practically 
unknown. There are only two other conditions which 
could have been mistaken for tetanus in this case — hys- 
teria and rheumatism. The latter frequently causes a 
stiffness and soreness of the muscles of the neck not un- 
like commencing tetanus, but rarely If ever affects the 
jaw. The patient was not subject to rheumatism, and 
had not caught cold, while her abortion, possibly self-in- 
duced by septic instruments, had certainly opened a chan- 
nel for Infection. Hysteria may more or less closely sim- 
ulate tetanus. In regard 10 the differential diagnosis 
Gowers says: "In hysteria, tetanoid spasm is rare ex- 
cept as part of a convulsive attack, but trismus causing 
persistent closure of the jaws occurs in hysteria. It may 
succeed a convulsion and last till another, or may come 
on without obvious cause, continue a few hours or days 
and then suddenly vanish. It Is prone to recur, and this 
character, the suddenness of onset, its complete degree, the 
absence of rigidity in the neck, and the presence of other 
symptoms of hysteria rarely leave any doubt as to its 
nature." There were no other symptoms of hysteria, 
nor was there any history of previous hysterical attacks, 
so that this fact, with the marked rigidity of the neck, 
enables us to exclude this condition. 

White and Peterson say of hysterical trismus: "It 
usually appears suddenly after a hysterical convulsion and 
suddenly disappears and recurs, and lacks the nuchal 
rigidity and mental clearness of tetanus." The prompt 
response of the disease to the injection of the serum, 
which was used as soon as the diagnosis was made, 
favors the view that one reason for the slight benefit of 
serum treatment of tetanus hitherto has been its too late 
use. White and Peterson enjoin the early use of the se- 
rum, in addition to other therapeutic measures, and ex- 
press the hope that it may be improved so as to be more 
efficacious. 



MEDICAL PROGRESS. 



An Obscure Complication of Varicocele. — Smyth {.\foii- 
trcal Med. four., June, 1S99) mentions a peculiar com- 
plication In a case of varicocele. It w-as a nodular mass 
which appeared in the upper part of the scrotum, very 



July S, 1899] 



THERAPEUTIC NOTES. 



43 



tender and giving the patient intense pain. The testicle 
was not affected nor was there anything to be felt in the 
Inguinal canal, though the dragging pain extended up- 
ward into it. Manipulation under chloroform produced 
no evident effect, and aspiration with a needle drew only 
fifteen minims of dark blood. The patient was taken to 
the hospital in an ambulance. During the journey he 
felt a sudden relief, and examination a short afterward 
showed that the tenseness had entirely disappeared. 
There was in the upper part of the scrotum a soft, tender 
nodule, apparently the result of the numerous hypodermic 
pricks, and a tender nodule was telt to the inner side of 
the internal ring. Operation was performed but nothing 
was found. The writer considers the differential diagno- 
sis between hernia and a strangulation of one vein by the 
loop of another, and decides m favor of the latter com- 
plication. The patient recovered. 

Cleaning the Hands with Horsehair FoRBES {P/iil. 

Med. Jour., May 20, 1899) takes a flat bunch of curled 
horsehair instead of a brush and uses it in cleaning his 
hands, and preparing the operative field. The hairs are 
stiff enough to scrape away particles of dirt, and will not 
scratch the most delicate skin, as will the bristles of a 
brush. This little mop of hair can be sterilized and used 
for months without losing its character. 

Neglect of the Teeth before and after Dentition Head 

(Ther. Gaz., May 15, 1899) takes to task those who 
prescribe acid medicines without cautioning patients to 
protect their teeth from their influence. He says many a 
dentist has carefully brought a child up to the age of fif- 
teen years, and then has seen his efforts spoiled by the 
medicine given in some acute illness. Another precau- 
tion wofully neglected is the washing of the mouth every 
four hours, during a severe illness. Some mild antisep- 
tic solution should be held against the teeth for not less 
than two minutes each time. Milk of magnesia should 
be used at bedtime to protect the teeth from acid mucus 
during the night. 

Head is a strong advocate of the lancing of painful 
teeth in infants. The pressure of one tooth upon a 
healthy nerve, while its edge is cutting through the gum, 
may not upset a child. But if the child is irritable, or if 
several teeth are coming at once, the physician should 
lance the gums. There need be no dread of making the 
gums hard by scar tissue, as no tissue in the body is more 
yielding than that of a scar. 

Results of Operation for Stricture of the Urethra. — 
Israel (Deut. Zeitschr. f. Cliir., vol. 51, p. 239), after 
an examination of the records of all the patients with 
stricture operated upon during the past eight years in the 
Moabit Hospital in Berlin, combined as far as possible 
with an examination of the patients in their present con- 
dition, advocates internal urethrotomy rather than exter- 
nal urethrotomy in all cases in which the stricture is in 
the bulbous portion. He found this to be the commonest 
seat of stricture, those patients who had strictures in the 
pendulous portion usually having one in the bulbous 
portion as well. Four patients died after operation, one 



of the deaths being due to miliary tuberculosis, and the 
others to shock, uremia, and sepsis. These all occurred 
in patients upon whom external urethrotomy had been 
performed. 

Celluloid Thread for Sutures and Ligatures. — PaGEN- 
STECHER (Dt'it/. .Med. VVoch., April 6, 1899) takes a 
good thread, boils it for half an hour in a one-per-cent. 
solution of soda, washes it in boiling water, and then 
dries it between sterile compresses. He then soaks it in 
a solution of celluloid, and passes it again through the 
same solution. Afterward it is sterilized by steam under 
pressure, and preserved for use either dry or in an alco- 
holic solution of bichlorid of mercury. Such threads 
have a smooth surface, they never tangle, they cannot 
absorb secretions, and are easily tied. For three years 
Pagenstecher has used these celluloid threads, to the ex- 
clusion of silk, and the use of catgut for ligatures has 
been greatly reduced. The results have been of the best, 
and the saving in expense considerable. 

Trophic Affections of the Bladder Following Pelvic Opera- 
tions. — After such operations, especially vaginal hyste- 
rectomy, symptoms of cystitis sometimes appear which are 
attributed to the presence of ligatures in the wall of the 
bladder. Mirabeau after cystoscopic examination of a 
number of such cases states the condition to be one of 
atrophy of the mucous membrane with areas of edema 
which he attributes to trophic disturbances resulting 
from section of nutrient vessels. He found no ligatures. 
He considers the usual treatment, especially intravesical 
treatment, to be injurious, and advises stimulation of the 
local circulation by means of abdominal and vaginal 
massage, applications of iodin, glycerin, and sitz baths. 



THERAPEUTIC NOTES. 



A Common Cause of Crying in the New-Born and Its Belief 
by Water. — SOUTH WORTH {Canada Lancet, May, 1899) 
suggests that the uric-acid infarctions in the kidneys of 
the new-born may be a source of irritation and a cause 
for crying if the scanty supply of urine washes them out 
with difficulty. Thus a baby which had cried almost all 
of the second day of its life and had passed, during this 
time, no water, emptied its bladder of a half ounce of 
turbid brown urine when the cool hand was placed upon 
it. Boiled water, which should be given to the infant 
regularly pending the establishment of lactation, will dilute 
the urine and alleviate such discomfort. 

Posture in Occipitoposterior Positions. — Green {Bost. 
Med. and Surg. Jour., May 25, 1899) says that the ad- 
vantage to be gained in the treatment of occipitoposterior 
positions by a proper application of the force of gravity is 
not as well known as it should be. He mentions an in- 
stance in which he was able to obtain a change from a 
posterior to an anterior position after the rupture of the 
membranes, but before pains had come on, simply by 
keeping the mother kneeling at the bedside a good part 
of the day. The following day she was delivered, after 



44 



THERAPEUTIC NOTES. 



[Medical News 



four hour's labor, of a ten-pound child. Even afier the 
head is in the pelvis the assumption of a lateroprone po- 
sition on the side toward which the occiput is directed 
will generally effect rotation in cases in which it could 
only be brought about by manual interference if the pa- 
tient remained continuously on her back. During the last 
week of pregnancy Green often advises a woman to lie at 
night in the lateroprone position, on the side toward 
which the occiput is directed, being able thereby to con- 
vert a posterior into an anterior position. During the 
first stage of labor the kneeling posture can be assumed 
from time to time with profit and comfort to the patient. 
When rotation has been obtained delivery can be accom- 
plished in any prone position that is preferred. 

The Control by Arsenic of the III Effects of Thyroid Ex- 
tract. — Mabille {Rev. lie Therap., May i, 1899) hopes 
that he has found in arsenic a means of preventing the 
ill effects of thyroid extract, which are produced in some 
patients by this drug. The increased use of the thyroid 
gland, not only for myxedema, but for obesity, goiter, 
certain skin diseases, and in general for malnutrition, 
makes it important that there should be some means of 
controlling the vertigo, palpitation, dyspnea, anxiety, 
etc., from which patients who are particularly sensitive 
suffer. The writer observed that these symptoms disap- 
peared in one of his patients when she was taking 
Fowler's solution and reappeared when she stopped the 
arsenic. From 2 to 1 2 drops of Fowler's solution at a 
dose were found to be sufficient to prevent any unpleasant 
symptoms even when taking 12 grains a day. Two other 
patients took arsenic with thyroid extract with happy re- 
sults, and the arsenic did not weaken, apparently, the 
force ol the thyroid extract. 

Bromid of Ethyl Anesthesia — LarisCH {Centralbl. f. 
C/n'r., April 15, 1899) gives in the lorm of an inaugural 
dissertation the experience of Pjrtsch with bromid of 
ethyl narcosis. Alter using this anesthetic upon more 
than 120 patients this surgeon is enthusiastic in its favor, 
and regards it as an ideal anesthetic. The accidents 
which followed its use some years ago and which gave it 
such a bad name were due, he claims, to the administra- 
tion of too much or too-concentrated vapor, or to the use 
of impure preparations. He employs only the purest drug 
(Merck's manufacture), dropping it on an ordinary chloro- 
form mask. A stage of excitement was observed in only 
eight per cent, of adults and in no children. All patients 
wakened from unconsciousness very quickly and vomiting 
occurred in less than two per cent, of the cases. As the 
heart-beat and respiration are scarcely affected by it, the 
anesthetic is particularly useful in cardiac cases, and as 
it is quickly dissipated from the system, but not at all by 
the kidneys, it is recommended for use upon patients suf- 
fering from grave constitutional maladies, such as dia- 
betes, sepsis, etc. The reflexes are never entirely abol- 
ished during its administration so that it requires a little 
practice to know how deeply a patient is under it, but 
the muscular system is sufficiently relaxed to permit of 
the reduction of fractures, etc. For use in minor sur- 
gery it has no equal. 



The Coated Tongue. — Weaver (New York Med. 
Joiir., Ma> 13, 1899) says that the coating of the furred 
tongue is full of fungi, and that the bacteria, innocent or 
infectious, as the case may be, are washed into the 
stomach with each meal. In disease there are abnormal 
elements in the secretions and excretions. When ab 
normal saliva is thrown into the mouth and subjected to 
the action of the numerous micro-organisms of fermenta- 
tion, more or less of the solid matters are thrown down 
and constitute a salivary precipitate, which lodges on the 
teeth and on the dorsum of the tongue, also on the gums 
and lips, which, in cases of typhoid fever, is known as 
sordes. This sahvary precipitate can be recognized on 
the teeth, as it roughens their surface. It is easily re- 
moved by the use of the tooth brush. It covers the teeth 
as a whitish deposit which microscopically shows the dif- 
ferent forms of micrococci and bacilli. Upon the tongue it 
is allowed to remain until it becomes very offensive, un- 
less it is systematically removed by scraping. 

When a physician is consulted regarding a foul breath 
or coated tongue he ought to advise the patient to pro- 
cure a tongue-sctaper and diligently clean the tongue 
every morning as a part of the morning toilet, using after 
it a disinfectant mouth wash on the tongue and as a den- 
tifrice. This method will remove the foulest odors from 
the breath. The same deposit appears on the tongue 
every morning and must be removed as often. 

Every surgeon who has a coated tongue and wishes to 
be aseptic should look to this possible source of infection, 
for in coughing, sneezing, or even speaking, it is known 
that the breath takes with it particles of moisture from 
the mouth and throat. And every patient who is to have 
an operation about the mouth or throat should have his 
tongue cleaned and disinfected. Every fever patient 
should have his tongue systematically cleaned to remove 
just that much self-infection. And every person who 
wishes to be agreeable in the society of others should re- 
move the foul coating on the tongue and with it the 
offensive odor of the breath. 

Prophylaxis of Ophthalmia Neonatorum. — CASTILLO 
(Rev. de Therap., April 15, 1899) says that many 
troublesome affections of the eye. which sometimes re- 
sult in blindness, might be avoided if accoucheurs were 
more careful in the use of prophylactic measures. The 
genitals of every pregnant woman ought to be minutely 
examined. If there is a leucorrhea it should be examined 
bacteriologically, since the presence of gonococci intro- 
duced perhaps by the father, who thinks himself com- 
pletely cured of an old gonorrhea, makes antiseptic irriga- 
tions preceding the confinement especially necessary, 
though they should be used whenever there is original 
discharge. When the child is born it should have its eyes 
wiped immediately with absorbent cotton and then washed 
with boiled warm water. The use of antiseptics is not 
advised except in those cases in which the vaginal secre- 
tion of the mother contains gonococci. Or to insure 
greater safety a solution of formal i to 1000 may be used 
daily, as it is not irritating and has both an antiseptic and 
anesthetic action. 



JULV 8, 1899J 



CEREBROSPINAL MENINGITIS AS A PANDEMIC DISEASE. 



45 



The Medical News. 

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SATURDAY. JULY 8. 1899. 

THE BUBONIC PLAGUE AN D U R W E S T E R N 
COAST. 

We quoted some time ago from the Indian Med- 
ical Record the editorial opinion that Bombay and 
Calcutta were doomed citie?, because of the practical 
impossibility of ever getting their sanitary condi- 
tions into reasonably good shape. It is evident 
then that the present danger to the civilized world 
from plague is to continue for some time, and that 
it is not so much special precautions against inci- 
dental exposure, because of a single infected vessel, 
as a thorough system of quarantine against certain 
Eastern ports that is needed. The conditions that 
have developed for the United States in the Far 
East during the last year emphasize the necessity 
for a complete and uniform system of quarantine on 
■our Western Coast. Our commercial intercourse 
with the East is assuming much more importance 
than before. The annexation of Hawaii gives us 
another and most vulnerable point in the matter of 
public health and the importation of disease. 

The work of the Marine Hospital Service has 
so far been effectual, and its service can be de- 
pended on to institute effectual quarantine wherever 



its powers and facilities are adequate. With our ex- 
tensive Western coast line, however, under the new 
conditions that are coming in, the lack of uniform- 
ity in quarantine regulations may constitute a serious 
source of danger. That good quarantine regulations 
can be effective British colonial history for the 
last four years proves. Despite the existence of 
the plague at a number of important points 
along the lines of colonial commerce the British 
Government has been able to prevent its spread 
from the originally infected districts. The suc- 
cessful international quarantine of the Red-Sea 
district and of the Suez Canal has been especially 
deserving of applause and has shown how much can 
be accomplished by modern sanitary science in the 
face of the most serious difficulties if it is but given 
the opportunity. 

The problems involved in our own quarantine 
regulations, East and West, against yellow fever and 
the plague, make evident the necessity of some cen- 
tral authority clothed with plenary power and uniform 
regulations to take eomplete charge of both our sea- 
boards so as to effectually guard the country's health. 
The American Medical Association at its recent 
meeting voiced the sentiment of the medical profes- 
sion of the country in formally counselling the estab- 
lishment of a National Department of Public Health, 
to be presided over by a member of the President's 
Cabinet. As our commercial relations become more 
extensive this becomes more and more a necessity. 
Let us hope that its advent will not be delayed un- 
until some epidemic makes fatally plain the lesson 
that is so patent already. 



CEREBROSPINAL MENINGITIS AS A PAN- 
DEMIC DISEASE. 

As we noted editorially at the time, the discussion 
of cerebrospinal meningitis at the recent meeting of 
the American Medical Association at Columbus 
brought out especially the fact that the disease is 
much commoner here in America than is generally 
supposed or the text-books seem to teach. But 
practically the same thing appears to be true all over 
the world. The crowding together of soldiers in 
this country under especially unhygienic conditions 
during the recent war led to an outbreak of the dis- 
ease as an epidemic in several of the camps. Dur- 
ing the late Turco-Grecian War reports of the same 



46 



PATENTED DRUGS. 



[Medical News 



tenor came from both armies. At Omdurman and 
Khartoum the British soldiers suffered in a similar 
way, and the epidemic at Omdurman was especially 
severe and fatal. 

It would seem then that the germs of the disease 
are practically universally present, and that only a 
favorable opportunity is necessary, as when resistive 
vitality is low, to give the disease a suitable nidus. 
And after its passage through a series of susceptible 
organisms it takes on a virulence that makes it 
fatally epidemic in character. Its manner of trans- 
mission remains as yet a mystery. During the pres- 
ent year we have had reports of the disease as an 
epidemic in various parts of the country, especially 
in the middle West and South, and our Philadelphia 
correspondent quotes from the Pennsylvania State 
Board of Health reports the statement that there 
were in the city of Philadelphia during the month of 
May twenty-two cases of cerebrospinal meningitis 
with fourteen deaths. The subject of the frequency 
of the disease and its mode of transmission evidently 
demand careful investigation. 

The affection has of late acquired additional in- 
terest from the announcement by Professor Schultze 
of Bonn [Muenchener Medicinische Wochenschrift) 
that, in a case of typical anterior poliomyelitis in 
which the subsequent course of the case — the atroph) 
of muscles, etc., had confirmed the original diag- 
nosis, lumbar puncture disclosed in the cerebrospinal 
fluid the presence only of the meningococcus intra- 
cellularis — the micro- organism that Weichselbaum 
demonstrated to be always present in fatal cases of 
cerebrospinal meningitis and which is generally ac- 
cepted now as the cause of that disease. If it should 
prove that anterior poliomyelitis in only certain 
cases is really a mild cerebrospinal meningitis (we 
have realized for some time that it is some form of 
acute infectious disease) it will greatly add to the 
interest of both affections. 

The sporadic cases of anterior poliomyelitis that 
occur with such comparative frequency and over so 
wide an extent of territory may help to explain how 
cerebrospinal meningitis is kept in existence and 
how its transmission occurs so insidiously. It would 
throw light too on the sudden and apparently unac- 
countable outbursts of the disease by recognizing 
that its passage through a series of susceptible or- 
ganisms has suddenly given it increased virulence. 



IS IT PROPER FOR A PHYSICIAN TO EM- 
PLOY A PATENTED DRUG? 

In discussing this question, it is necessary to clearly 
define at the outset what is meant by a "patented" 
preparation. Patent medicines, so-called, are not 
as a rule patented but are protected by being cc- 
corded a copyright of the name and by the customary 
use of that name as a trade-mark. Strictly speak, 
ing, a patent medicine is one which is made by a 
patented process, which process has been devised as 
the result of thought or experimental research, and 
is quite as much entitled to Governmental protection 
as is the result of the thought or experimental re- 
search which ends in the invention of any machine 
which is of distinct benefit to the human race. If 
the general theory of patents is correct, that the in- 
ventor of industrial articles is entitled to the sole 
benefit of his ingenuity for a certain period of years, 
the chemist is equally entitled to similar reward, as 
by reason of his skill he has produced a drug which 
is of distinct value to his fellow men. 

The term chemist or druggist here is used advis- 
edly, in distinction from the term physician, because 
it is generally held that the higher ethics of the 
medical profession does not permit its members to 
patent remedial drugs or instruments. We are 
therefore not in favor of physicians patenting the 
results of their genius, but the question before us 
is whether a physician shall use substances which 
have been patented by persons outside the bounds of 
the medical profession. 

It seems to us that this question should be an- 
swered unquestionably in the affirmative, first, be- 
cause many of these substances are of very decided 
value and, therefore, it is to the interest of the pro- 
fession to use them, and secondly, because the phy- 
sician has no right to deprive his patients of chemical 
products which he knows are specially indicated 
simply because he does not approve of the methods 
by which they are manufactured or protected. By 
force of circumstances, physicians have within the 
last few years continually prescribed remedies which 
are patented, as antipyrin. But the patents on an- 
tipyrin have expired, and the profession and laity 
are now enjoying at the simple cost of manufacture 
and distribution the benefits of the chemist's skill 
and labor without depriving him of the just reward 
that is universally granted to inventive genius. 



JULV 8, 1899] 



ECHOES AND NEWS. 



47 



There is a class of preparations which we believe 
physicians should carefully avoid using, namely, 
medicinal substances advertised to the laity. These 
should be avoided not from the business standpoint 
4hat they deprive the profession of practice, for this 
they do not do, because patients who take these 
preparations usually do so with such disastrous effects 
that the profession is pecuniarily benefited in the 
end by acute cases being transferred into chronic 
ones, but because the advertisement of these prepa- 
rations to the laity causes non- medical readers to 
dose themselves with compounds which in many 
cases are not only useless but distinctly harmful. 
The products of those manufacturers who sell a prepa- 
ration to the medical profession with the right hand 
and the same preparation to the laity with the left, 
should also be carefully avoided in writing prescrip- 
tions. 

ECHOES AND NEWS. 



Diplomas Given to Nurses — The Training School for 
Nurses of the Manhattan State Hospital on Ward's Island 
held its second annual graduation exercises on June 
14th. There were no graduates, of whom 69 were 
women. 

Dr. Austin Flint, President — Dr. Austin Flint was 
elected President of the Medical Association of the 
Greater City of New York, which held its stated monthly 
meeting at the Fifth Avenue Hotel in New York on 
June 12th. 

Increased Hospital Accommodations in Paris. — The 
Municipal Council of Paris is considering an expenditure of 
72,000,000 francs for the erection of additional hospital 
accommodations. This amount of money would be suffi- 
cient to provide 2810 new beds. 

Post-Craduate Medical School — The eighteenth annua! 
announcement of the New York Post-Graduate Medical 
School shows that 523 Doctors in Medicine from 57 
States, Territories and countries, have attended its courses 
during the year ending June I, 1S99. 

Wedding Gift to Hospitals — Mr. Arthur P. Heinze of 
Brooklyn and Miss Ruth Noyes of Butte, Montana, were 
married in the latter city on June 15th. After the cere- 
mony Mr. Heinze and his brother gave S5000 each for 
the establishment of emergency hospitals in Butte. 

Spurious Sanatorium Raided. — The house at 9 East 
Twenty-seventh street has been raided as a disorderly 
house. For the past year a woman calling herself Dr. 
Frances McCullough has conducted there what she termed 
a sanatorium. All the wTDmen were dressed as nurses. 

Fifty Ambulances Missing. — Fifty hospital ambulances, 
which were shipped from Chicago to Tampa, Florida, 



more than a year ago by the local army officials to be 
forwarded to Cuba for the use of the United States troops 
on the island have been lost. Thus far there has been 
no clue to the missing property. 

The Seaside Hospital. — The new building of the Seaside 
Hospital at New Dorp, Staten Island, was dedicated on 
June 16th to the work for which it was erected by St. 
John's Guild. The new building, which is an addition to 
the old one, is a four-story brick fireproof structure, and is 
fitted with the best modern sanitary appliances. Last 
year 2057 patients were treated at New Dorp. 

Expectoration in Hoboken. — Hoboken is setting a good 
e.xample. An ami spitting ordinance is being enforced in 
that city. Policemen are ordered to warn those who 
spit and to arrest upon a repetition of the act. There is 
a fine of $10 for the first offense and of $25 for a second 
offense. Spitting is prohibited in all public places except 
into cuspidors, which are furnished by the city. 

The Destitute Blind Relieved. — $35,000 in gold was dis- 
tributed among 700 blind men and women at the office 
of the Department of Charities of New York City on June 
13th. By a provision of the charter $75,000 is appro- 
priated for yearly distribution to the destitute blind of the 
■ city. The remaining $30,000 will be distributed among 
the blind poor of Greater New York outside the 
Borough of Manhattan. 

Typhoid along the Ohio.— It was reported from Wheel- 
ing, West Virginia, on June 1 3th, that typhoid fever is 
epidemic in many of the towns along the Ohio River from 
Pittsburg to Cincinnati. Its prevalence is attributed to 
the deleterious conditions produced by the big flood of 
last spring. It is noteworthy that towns having water- 
supplies far removed from the river have fared no better 
than communities which depend solely upon the muddy 
and filthy water of the Ohio. 

4 New Cancer Hospital. — On June 19th there was es- 
tablished in Perry street near Greenwich avenue in New 
York City a branch of the French Catholic Charity known 
as the "Women of Calvary" for the gratuitous treatment 
of indigent female cancer patients. The first House of 
Calvary was founded in Lyons in 1S42, and in 1874 
there was another established in Paris ; another in Saint 
Etienne soon followed, and in 1S81 a fourth in Marseilles. 
In 1 886 a house was opened in Brussels, Belgium, and in 
1892 another was founded in Rouen. 

The Working of England's Inebriate Act. — An attempt 
has been made recently to get a woman of North London 
committed to a drink-cure establishment, under the pro- 
visions of the Inebriate Act, which went into effect at the 
beginning of this year. It was shown that the woman 
had been convicted of drunkenness five times this year, 
but the magistrate refused to grant the request on the 
grounds that the act referred to respectable women who 
had fallen victims to the craving for drink, while the 
prisoner did not seem to him to be of that class. The 
case will be appealed. 



ECHOES AND NEWS. 



[Medical News 



No Bubonic Plague at San Francisco. — Dr. Wyman, 
surgeon general of the Marine Hospital Service, denies 
the existence of bubonic plague on the ship "Nippur 
Maru," in the harbor of San Francisco, as reported in the 
daily press. The two Japanese who jumped overboard 
from the ship were stowaways who connived with mem- 
bers of the ship's crew to escape, and were drowned in 
trying to evade the customs patrol which had been estab- 
lished around the vessel. They were strong men, and 
free from disease. The members of the crew and the 
passengers are all well. 

The Passing of homeopathy. — Under the above title the 
Cleveland Journal of Medicine records the fact that no 
less than fifteen homeopathic practitioners of that city, 
after having spent the winter in study at the Cleveland Col- 
lege of Physicians and Surgeons (regular; have received 
the degree of M.D. An equal number had previously done 
so, so that in Cleveland at least there seems some reason to 
justify the title to the item above given. The editor 
commends to the consideration of their professional 
brethren these men who have had the honesty to give up 
false claims at the cost of no little personal trouble and 
expense. 

Yellow Fever. — The Marine Hospital Service reports that 
from May 6th to 19th thert; were, at Rio de Janeiro, 
thirty-four cases and seventeenth deaths; at Havana, June 
8th to I jlh, one death ; at Matanzas, June 30th, one case. 
Ten cases were reported among the troops of the garri- 
son at Santiago on July ist, five cases July 2d, and 
five cases July 4th. There have been thus far seventy- 
nine cases of the disease there and fifteen deaths. The 
quarantine against the troops is very strict. No soldiers 
are allowed in the city except a small guard about the 
arsenal. There are no cases among the civilians. 

Tests upon Tuberculous Cows — Experiments upon tuber- 
culous cows which have been conducted at the Ohio Ex- 
periment Station throws some doubt on the correctness 
of the theory thit tuberculosis is communicated by the 
use of the milk of consumptive cows. Two years ago 
eleven cows were condemned by the tuberculin test. 
They were segregated, but in no other respect was any 
change made in their care. Their milk was fed to calves 
one of which, after having been thus nourished for seven 
months, showed no reaction with tuberculin, and no tu- 
bercles were found post-mortem. The eleven cows 
were slaughtered recently, and the government inspector 
condemned the carcasses of only two of them as being 
unfit for food. 

The Case against Dr. Cleaveland. — At the preliminary 
hearing on the third charge (two previous indictments 
having been dismissed for want of evidence) against Dr. 
Trumbull \V. Cleaveland, which was held before Magis- 
trate Wentworth on June 14th, Bartow S. Weeks, Esq., 
counsel for Dr. Cleaveland, read a long itemized bill for 
the Carhart baby's funeral expenses, which he said had 
been sent to Dr. Cleaveland for payment. The bill footed 
up to $727.60. Among a great many items were the 
following: Mourning for Mrs. Carhart, $35. mourning 



for Mr. Carhart, $1;, mourning cards and stationery, $3, 
stone §166, care of grave, $1, photographs of baby alter 
death, $20, vocal music at funeral, $20, organist, $20, 
sexton, Sio. a stateroom on Fall River boat, $2, etc., 
etc. This looks extremely like a case of malicious prose- 
cution. It is not surprising that the case, as announced 
in our last week's issue, was promptly dismissed. 

The Pestilential 'Christian Science." — The lay press 
daily reports cases of death and misfortune which are due 
to the presence among us of this pernicious cult. The 
evil IS becoming so great that in order to correct it some 
other means will have to be employed than mere ridicule 
which usually suffices to kill movements akin to this, 
such as have originated either in abnormal mental proc- 
esses, or in the deliberate purpose of their originators to 
humbug humanity. At Elgin, there died in the Illinois 
Northern Hospital for the Insane, on June iSth, Ellen L. 
Gilson. In this institution were also Gertrude, the 
daughter of the deceased, and Elmer E. Day, the brother 
of the deceased. All lost their reason through the study 
o' Christian Science. At Minneapolis, Minn., on June 
20th William E. Bradford died without medical attend- 
ance. He had been ill since June ist. Christian Scientists 
had "treated" him Miss Eva Banfield, a Christian 
Scientist, was sent to the Buffalo State Hospital on June 
22th, having become insane. Joseph Caig died in Phila- 
delphia on June 22d of "heart disease," so the autopsy 
showed. He had had no physician. A Christian 
Scientist was his "healer." At Falls City, Nebraska, the 
three-year-old child of George Sperry became ill. The 
mother, a believer in "divine healing," would not permit 
a doctor to be called. The child having rapidly became 
worse the father pleaded with a physician to treat it. 
This was done and the child grew better, and was 
on the road to recovery. One night the physician's 
son remained with the child and it was only by force that 
he administered to it, the "healers" swarming about him 
all the while, and saying everything he did was instigated 
by the devil. When the doctor left the next morning 
they threw the medicine away, locked the father in the 
kitchen, and praved over the child until it died. This was 
on June 22d. Mrs. Porcella of Cranford, New Jersey, 
died on June 22d. A year ago she became a Christian 
Scientist. Shortly after this she contracted a severe cold, 
which she paid no attention to. Then phthisis appeared. 
But she would not be treated by medical men until three 
weeks ago. Thus does the ghastly procession pass be- 
fore us. It is pleasing to be able to record that some 
steps are being taken to restrain this evil. At a meeting 
of the Medico-Legal Society of New York on June 21st 
the President was authorized to appoint a committee, 
whose duty it shall be to investigate the methods of the 
"Christian Science healers." In Philadelphia also some- 
thing is being done by the County Medical Society whose 
President, Dr. Soils Cohen, considers that "important is- 
sues in public health are involved which give the State the 
right to interfere in order to protect children and other 
helpless persons from their parents or guardians. More- 
over, these issues give the State the right to interfere to 
protect the community from contagious diseases which 



JULY 8, iSgg] 



THE AMERICAN MEDICAL STUDENT ABROAD. 



49 



may spread if not properly treated and do much harm to the 
community." 

Distinguished Medical Visitors to America. — In the decen- 
nial celebration of Clarke University, Worcester, Mass., 
which commenced July 5th, two distinguished foreign medi- 
cal men have taken part — Professor Santiago Ramon y 
Cajal of the University of Madrid, Spain, and Professor 
Angelo Masso of the University of Turin, Italy. Professor 
Ramon y Cajal will be recognized by American medical 
men generally as the well-known investigator into minute 
nervous anatomy, whose work during the last ten years has 
attracted world-wide attention. He is practically the only 
Spanish member of the medical profession whose work is 
known outside of the confines of Spain, and almost the 
only Spanish scientist who in our generation has made in 
any line distinct contributions to scientific knowledge. 
His work met with little encouragement in university cir- 
cles in Spain itself until the interest of the outside world 
in it compelled its recognition. Professor Ramon y 
Cajal has gathered around him at Madrid a corps of work- 
ers in minute anatomy, and especially in the normal and 
pathological histology of the nervous system, all of whose 
contributions are now eagerly awaited, and the results 
noted by all other workers in these lines. Professor An- 
gelo Masse is best known perhaps for his work in recent 
years upon the ductless glands, and especially upon the 
interesting questions involved in the parathyroid glands 
and their relation to the thyroid and to the general nu- 
trition and metabolic processes of the organism. A dis- 
cussion carried on through the medical journals for some 
time with Piofessor Gley of the Sorbonne on this subject 
brought him into a good deal of prominence a few years 
ago. It is to be hoped that both these distinguished 
medical visitors will meet with a suitable welcome from 
the; profession wherever they visit in this country. 



CORRESPONDENCE. 



TH E AMERICAN MEDICAL STUDENT ABROAD. 

MEDICAL STUDY .\T THE S.\t.\LLER GERMAN UNI- 
VERSITIES. 

For most medical men medical study in Germany means 
courses taken at Berlin or Vienna, or perhaps, Munich or 
Leipzig. Too often it is forgotten that the younger and 
more pushing men, the men with a present and a future 
in medicine, though perhaps not yet with a past, are as a 
rule doing their work in the small German university 
towns. Of course the younger men have not as yet won 
that reputation across the sea that the attainments of 
cider men have brought to them, but instead of resting 
on their oars in a very proper elderly conservatism they 
are pushing their way in the very forefront of medical 
advance; they are doing the vv-ork that will later put them 
at the head of clinics and departments in \ienna and 
Berlin and Leipzig and Munich, while just now they are 
in that precious stage of youthful enthusiasm for progress 
and discovery that makes personal contact vvith them an 



incentive to original work such as can be imparted in no 
other way. 

It is to be remembered that advancement ver>' seldom 
comes to the German assistant professor at the university 
where he spends his early years of teaching. He must 
have had some years of experience in charge of a clinic 
or institute atone of the smaller universities; he must 
have shown his prowess of initiative and his capacity for 
independent work before he will be called to a chair in 
one of the large universities. The present professors 
at Berlin and Vienna, for instance, have, with very few 
exceptions, passed through a preparatory novitiate at more 
than one smaller university before their call to the large 
cities. Professor von Leyden was at Konigsburg and 
Strasburg, Professor Gerhardt at Jena and Wurzburg, 
Professor Konig at Gbttingen, Professor Nothnagel of 
\'ienna after being assistant at Berlin was at Jena we be- 
lieve, Professor Gussenbauer was at Prague. It is well 
understood by the assistants at the large cl'nics that direct 
promotion at a great university is practically out of the 
question. "Unless" as one of them once said to me, "I 
should turn the medical world half upside down." The 
young men accept the full or ordinary professorships at 
the smaller universities, though as a rule the salary is not 
a very tempting one, because they fully appreciate that 
this is the next and essential step in their career as uni- 
versity professors. 

It is the work being done by these younger men parti- 
cularly that is keeping German medicine in the van of 
medical progress. Contact with them is a precious 
thing and should constitute a part of the prospect to 
every young American going abroad. Of course the 
work in the smaller university towns has its drawbacks 
because of the small amount of clinical and pathological 
material that there is to work with. It may readily be 
imagined that Jena with about 10,000 people, Marburg 
with 15.000, or Griefswald with something less than 
25.000 cannot furnish the variety of cases, the multiform 
complications and sequela, and the anomalous patholog- 
ical conditions that would be desirable for purposes of 
university and especially post-graduate study. It must 
be remembered, however, that practically all of the poorer 
classes, who represent a much larger proportion of the 
population than here in America, are treated at the hos- 
pitals and in the university dispensaries ; that the reputa- 
tion of professors brings material from the neighboring 
country side, and that certain arrangements are made 
to supply hiatuses in pathologicpl material by the univer- 
sity authorities from larger centers. 

The principal advantage to be derived from attendance 
at the smaller universities is that personal attention is se- 
cured in whatever the student undertakes, and if the 
worker or investigator be but serious in his labors nothing 
seems too much to do for him The contrast in this re- 
gard fi'om the spirit of indifference or perfunctory fulfil- 
ment of duty that has been paid for which so often char- 
acterizes the attitude of clinical assistants and others 
engaged in work with Americans at the larger universities 
is most notable. For the theoretic branches espec ai y, 
for pathological ana:o:ii\ . 'o-phys o'ogy. lor bacteriology. 



so 



THE AMERICAN MEDICAL STUDENT ABROAD. 



[Medical News 



and the like the smaller universities are in a position to 
give much more thorough and satisfactory courses to 
those who really seek a thorough knowledge of certain 
subjects in medicine and not a hasty superficial glance at 
everything medical knowable and a few other things 
besides. 

Additional advantages at the smaller universities are 
that the absence of large numbers of Americans with 
whom in the larger cities the student is continually thrown 
in contact enables him to pick up German much sooner 
and better. Constant association with Germans forces 
the knowledge of the language upon him in less than half 
the time that the student in the larger cities requires un- 
less he is eternally vigilant in grasping opportunities. 
Another advantage and one not to be despised is the 
knowledge the student gets of real German university 
life and of the German university town as such. Large 
cities are unmaking the old university life all over the world 
and it is becoming harder and harder to understand certain 
historical details that German university towns still pre- 
serve. To one who is interested in German national 
life (and what doctor is not interested in knowing the peo- 
ple as they are) life in a small town will give certain true 
impressions of the genuine national life of the people that 
cannot be obtained in a large city. All the large cities 
of the world are being recast in the inodern mold of 
practical municipal advancement which is rapidly doing 
away with all that is characteristic in them, and the peo- 
ple are being modified by their environment. The true 
spirit of advance has not yet touched the smaller towns 
or only enough in passing to make them sanitary dwelling 
places without interfering too much with their interesting 
natural conditions. 

After this rather long prelude I may add a word or two 
of some of the smaller German universities at which I 
have had a brief personal experience, sufficiently recent 
for my impressions of them to be of practical service to 
others perhaps who may contemplate a European medical 
pilgrimage in the near future. 

Bonn is beautifully situated just on the most picturesque 
part of the lower Rhine, below the Siebengebirge, the 
famous scenic seven mountains and is the fashionable one 
of the German universities. To Bonn the present Em- 
peror went as a student and many of the sons of the 
German nobility go there for part of their course at least. 
The opportunities for work are excellent and the material 
(Bonn has some 50,000 inhabitants) reasonably plentiful. 
Schultze in medicine, Schede in surgery, and Pellman in 
mental and nervous diseases are all well and widely 
known. They are not young men but they have asso- 
ciated with them some excellent assistants and are them- 
selves not beyond their days of enthusiastic investigation. 
Bonn has the disadvantage from one point of view of 
having a good many English and American visitors dur- 
ing the summer semester, but is a delightful place in 
which to stay. 

Griefswald in the distant north not far from the Baltic 
Sea is a very charming old town, whose university, owing 
to the rivalry with the University of Rostock in the duchy 
of Mecklenburg-Schwerin.is kept at a very high standard 



by the special efforts of the Prussian Government, which 
takes this means (and a very good one it is) of demon- 
strating the advantage of living under Prussian rule. In 
the faculty are Loffler, Grawitz, who is prominently men- 
tioned as the prospective successor of Virchow at Berlin, 
Mosler in clinical medicine, and Landois the physiologist, 
whose text-book is so well known in this country. I do not 
know of any place where a summer semester of investiga- 
tion or experimental work in one of the theoretic subjects 
with occasional excursions into practical medicine could be 
passed more pleasantly than here on the cool pleasant 
shores of the BaLic Sea. 

Heidelberg is, if possible, more beautifully situated on 
the upper Rhine than Bonn lower down. Around it 
cluster some of the most characteristic traditions of Ger- 
man university life, and the German student, with all his 
oddities, the only ones we are apt to consider at a dis- 
tance, and his many e.xcellent and admirable qualities 
which only intimate association with him brings out, 
may be seen to better advantage here than anywhere 
else. Erb and Czerny are here, which is enough to say 
from a medical standpoint, but there are others. 

Jena is one of the old German universities not so noted 
for medical as for other work but where excellent oppor- 
tunities are given. Stintzing in medicine, known espe- 
cially for his work in therapeutics, Riedel who has made a 
name recently in surgery of the biliary tracts, Binswanger 
in mental and nervous diseases, and Ziehen in physio- 
logical and pathological psychology are here. 

There is an air about Jena in its picturesque location, 
in the midst of its traditions, in the pretty old university 
town as yet unspoiled by any, even the slightest, tincture 
of progressive modernity that makes a stay there most 
interesting. 

Marburg is another university town that is most beau- 
tifully situated. These four : Bonn, Heidelberg, Jena, 
and Marburg do not suffer by comparison with one 
another as far as regards picturesque situation. The 
two first are better known to the tourist because of their 
situation on the Rhine, but personally I should not care 
to have to make the choice from their scenic advantages 
alone. Marburg like Greifswald has been especially well 
cared for because of its nearness to a rival university, 
Giessen in the duchy of Hesse. It has a magnificent set 
of new university buildings and especially an entirely new 
set of medical clinics. Mannkopf is here in medicine, 
Kiister, whose work especially in renal surgery has 
brought him into prominence of late, is in charge of the 
surgical clinic. Frederick MuUer is here as an extraordi- 
nary professor in medicine, Behring is here and has be- 
sides the university laboratory in the town a magnificent 
private laboratory most beautifully situated on the heights 
above the town. The whole faculty at Marburg is far 
above the average. The salaries paid professors are 
higher than those at other universities because of certain 
funds that come to the Prussian Government and certain 
obligations it assumed in the matter of university and 
public education w-hen it deposed the reigning duke and 
took up the ruling power in 1866. 

The German university at Prague can scarcely be 



JULV8, 1899J 



MEDICAL MATTERS IN CHICAGO. 



called one of the smaller German universities despite its 
scant 300 medical students. There is no dearth of material 
for clinical and pathological work. Of the infectious 
diseases generally, even smallpox, of contagious skin dis- 
eases or those due to dirt and neglect ; of the varied com- 
plications of disease due to lack of sanitary arrangements 
Prague has a most abundant supply. Great improve- 
ments in sanitation have been made in recent years, but a 
large field for clinical work in the branches that depend for 
their material on defective sanitation still remains. From 
the well known character of the professors at Prague it 
seems needless to add that excellent advantage is taken 
of the material so amply provided. Von Jaksch and 
Pribraam in medicine, Wolfler in surgery, Pawlik in 
gynecology, Ganghofner in children's diseases, Chiari in 
pathology, the two Picks, one in dermatology the other 
in neurology and mental diseases are all names to con- 
jure with in the medical world. Of course Prague has 
for years been noted for its excellent teaching in obstet- 
rics and still retains her reputation in this respect. On 
the whole the opportunities lor study at Prague are excel- 
lent and are not taken advantage of as much as they 
would be if the conditions were known better abroad. 

I have mentioned somewhat in detail these six German 
universities because of personal familiarity with them. 
By reputation one gets to know in Germany certain other 
universities that present some good opportunities. Bres- 
lau, where the rivalry with the Austrian universities has 
led the Prussian Government to devote a good deal of 
money and energy to the making of an excellent univer- 
sity in all departments and many of whose professors are 
among the best known in German medicine. The 
University of Gottingen of other fame than medical but 
where Orth, who is also prominently mentioned as Vir- 
chow's possible successor, is doing some excellent work 
in pathology ; Strasburg, where Von Recklinghausen's 
work in pathology is well known, Naunyn is doing some 
of the best clinical and experimental work in Europe, and 
Minkowsky's physiological observations are eagerly 
looked for by the medical world. No effort has been 
spared by the German Imperial Government to give the 
new German university that succeeded the French uni- 
versity one of the best teaching faculties in Europe, and 
a teaching plant second to none. In this, as in every- 
thing else that Germany has seriously undertaken of late 
years, it has succeeded admirably. 

I fear that my catalogue of the minor German univer- 
sities has extended itself until it has lost its value as 
counsel and become a mere list. Very few German med- 
ical students, however, limit their studies to two univer- 
sities, but spend at least a semester at three or four. 
The plan has its advantages in the breadth of view it gives 
as to the comparative value of certain lines of medical ad- 
vance. It would certainly be of distinct benefit to Amer- 
icans not to limit themselves to any one school of teaching. 
Attendance at several universities demands several years 
abroad, however, and the American student is apt to go 
with the idea that he can absorb all that he will care to 
in a year or less. The sooner this notion is aban- 
doned the better. 



The Americans and Englishmen whose foreign studies 
have been of special service to them, of whom the late Pro- 
fessor Kanthack of Cambridge, and our own Professor 
Welch of Johns Hopkins are notable e.xamples, have all 
spent considerable time at patient investigation, usually in 
one definite line and without spending themselves on a 
number of^ubjects. It is this readiness to devote sufficient 
time and care to medical investigation that constitutes, as 
I called attention to once before in the Medical News, 
the essence of the good work done by the Japanese medi- 
cal students in E urope. When the younger American 
medical students are ready to devote themselves in the 
same way to patient clinical or experimental work not for 
one, but for two or more years, they will return after 
their European experience much better fitted to take up 
the work of advancing scientific medicine in America 
than now. when application to too many supposedly prac- 
tical subjects gives but a superficial knowledge of many 
things that are not long of benefit to the rising medical 
man. 

JA.MES J. Walsh, M.D. 

1973 Seventh avenue. New York Citv. 



BLOODLESS TONSILLOTOMY. 
To the Editor of the Medic.-^l News. 

Dear Sir : — For quite a number of years I have been 
very interested in the excision of tonsils, and in reading 
the article by Dr. Dawbarn, in the Medical News of 
May 2oth, thought that his idea a good one. Although 
I have never had a severe case of hemorrhage from a 
tonsillotomy I have always expected it, as I find the ton- 
sils in children, as a rule, do not bleed much and are de- 
void of blood-vessels. I avoid taking out tonsils in 
adults as much as possible, especially if they are hard, 
and always examine with my finger to find out whether 
there is any anomalous condition of the arteries. Dr. 
Dawbarn 's article, entitled "Bloodless Tonsillotomy, ' in 
the Medical News of June loth, is a thing not entirely 
to be desired, as I think the local blood-letting that comes 
from tonsillotomy is a part of the good which is derived 
from the operation, and which you also get from the opera- 
tion on the tonsil of Luschka, or on adenoids, and when I 
have very little bleeding I frequently use a little friction to 
bring it about. The mouth-breather, or the child with 
chronic hypertrophied tonsils, is the patient that gives the 
throat and nose specialist the most trouble to-day, and 
when the physician can relieve the patient he receives the 
thanks of the parents. Yours truly, 

Carr Lane, M.D. 
St. Louis, June 24, 1S99. 



MEDICAL MATTERS IN CHICAGO. 

IFrom Oar Special Correspondent.] 

ILLINOIS society FOR THE PREVENTION OF CON- 
SUMPTION — STATE BOARD OF HEALTH .M.\TTERS — 
ANNUAL MEETING OF THE CHICAGO .MEDICAL SO- 
CIETY. 

CHICAGO, July 3, 1S99. 
A MEETING of prominent physicians and laymen was 
held June 20. 1899, in the Hail of the Chicago Medical 



MEDICAL MATTERS IN CHICAGO. 



[Medical News 



Society, and the organization of the Illinois Society for 
the Prevention of Consumption was effected. Several 
speeches were made in which measures both for the pre- 
vention and extermination of the disease were discussed. 
Dr. L. G. Marillat. speaking on behalf of the Chicago 
Veterinary Society, presented a summary of the points 
which he said could be easily demonstrated: (i) That 
the tuberculin-test for bovine tuberculosis is sufficiently 
reliable to be practical. (2) That the sale of milk from 
tubercul us cattle should be absolutely prohibited, and 
that the apparent absence of tuberculous processes in the 
mamma of a cow is no assurance of non-infectious milk. 

(3) That tuberculosis is raging among the dairies of Chi- 
cago and vicinity, and the people of Chicago are actually 
being infected with tuberculosis through its milk-supply. 

(4) That proper veterinary inspection of dairies will even- 
tually result in purifying the supply, and such inspection 
should be conducted under the direction of the Commis- 
sioner of Health of Chicago, who in turn should collab- 
orate with the State officers in their efforts to e.xterminate 
the disease from domestic animals. Dr. A. S. Alexander 
said that in order to insure absolutely w-holesome. pure, 
innocuous milk we must have, first, a perfectly healthy, 
clean cow. Second, she must be fed on perfect, sound, 
sweet, nutritious food. Third, she must drink uncon- 
taminated water. Fourth, she must be surrounded by a 
perfect sanitary environment and housed in a fine stable. 
Fifth, the milk so produced must be protected against 
secondary infection. Tuberculosis may be eradicated 
from any stable by the proper use of tuberculin. Dr. 
William A. Evans discussed the mottality of tuberculosis 
and gave the annual mortality statistics from this disease 
in the large cities ol the world. The following officers 
were elected : Honorary president, Dr. N. S. Davis, Sr. ; 
president. Mr. John MatLaren; first vice-president. Dr. 
William A. Evans; second vice-president. Dr. Edwin 
Klebs; third vice-president. Dr. A. H. Baker; secretary, 
Dr. John A. Robison ; treasurer, Mr. Elbridge G. Keith 

The efforts of the Society with regard to legislative ac- 
tion will be: To urge the Slate Legislature to appro- 
priate a fund adequate to the needs of the State Board of 
Live Stock Commissioners, this sum to be probably S50, - 
000 for the ;irst year, S30.000 the second, and §20.000 
the third. To insist that the Legislature increase the ex- 
ecutive force of the Live Stock Commission sufficiently to 
enable the Commission properly to fulfil its duties. To 
urge that the Commission be empowered to administer 
the tuberculin test to all cattle in the State without the 
consent, or if necessary, against the wishes of owners of 
cattle. To make it necessary that the Commission begin 
a systematic examination of all cattle in the State, and 
all cattle not proving under the tuberculin-test to be free 
from tuberculosis shall be condemned, and the owners 
compensated by the State at the scale of prices fixed by 
the Live Stock Commissioners. To devise and recom- 
mend an efticacious plan for the prevention of the sale of 
tuberculous milk in Chicago; this plan modeled for the 
ii.ost part after the method adopted by Buffalo; to recom- 
mend that the Common Council enact an ordinance cre- 
ating a force of experts in veterinary medicine, whose 



duty it shall be regularly to insoect the dairies supplying 
milk to the Chicago market, whether or not such dairies 
be within the city limits; and the plan further to provide 
that no can of milk shall enter the milk depots of Chicago 
without a number corresponding with a number on the 
sanitary report of the dairy from which the milk was 
shipped. 

The State Board of Health, at its meeting held in this 
city recently, adopted resolutions calling on the Legisla- 
ture to vest the Board of Live Stock Commissioners with 
authority to conduct sweeping investigations looking to 
the eradication of tuberculosis in cattle and to grant a 
special appropriation for the work. The Board voted that 
Illinois municipalities ought to pass ordinances prohibiting 
the sale of milk from untested herds. The Board re- 
voked the practising licenses of H. E. Colby and William 
F. Hughes 

In the slaughtering of condemned cattle by the Live 
Stock Commissioners on June iSth out of 91 cattle 
slaughtered, 89 were found to be infected with tubercu- 
losis, and 57 were so badly affected that the carcasses 
were condemned. 

At the annual meeting of the Chicago Medical Society, 
held June 21, 1899. the president. Dr. Arthur D. Bevan. 
deliveied an address on "The Science of Medicine and 
Its Relations to the Public." He said there is a science 
of medicine just as truly as there is a science of chemistry 
or of astronomy or anatomy. Just as chemistry is de- 
pendent on physics and mathematics, so medicine is de- 
pendent on chemistry, physiology, pathology, and anat- 
omy. Medicine does not hesitate to borrow from any 
branch of knowledge that may aid in its development, 
and it follows that as these aiding sciences develop, med- 
icine will advance. Medicine must let the world know 
that it begins the twentieth century as a pure science, 
and that it has left behind it the mystery, the superstition, 
the dogmas of the past. The teaching of medicine must 
be in the hands of scientists. Students of medicine 
must be taught its truths and limitations. The public, 
with its ever growing ability to grasp knowledge, must be 
taught its truths and frankly told of its limitations. He 
then discussed the great duty which the science of medi- 
cine owes to the public under four heads : First, by de- 
veloping and teaching the science and practice of medi- 
cine along purely scientific lines. Second, by demanding 
a high standard of knowledge and efficiency of men de- 
siring to practise medicine. Third, ty educating the 
public in the great truths of medical science. Fourth, by 
obtaining national. State. and municipal recognition of the 
great medical truths which can be incorporated into laws 
for the good of the community. Of twenty medical col- 
leges in Chicago, he said possiojy there were three suffi- 
ciently well conducted to warrant their recognition as 
scientific schools ; the others have no right to such a claim. 
They represent either some paliry or a pathologic desire 
of a group of men for the title of professor and the op- 
portunity to advance and advertise themselves. This 
results in the turning out of poorly equipped medical men 
and the lowering of physicians generally in the eyes of 
the public. Modern medicine demands a scientific train- 



July 8, 1899] 



OUR PHILADELPHIA LETTER. 



53 



ing. The modern medical school must drill its students 
m the sciences of anatomy, physiology, pathology, chem- 
istry, and pharmacology in well equipped laboratories. 
These laboratories must be not only teaching mediums, 
but workshops for the discovery of new truths. After 
this preliminary work the student will study medicine, 
surgery, obstetrics, and the specialties in well-equipped 
hospitals and dispensaries. He would like to ses a 
national law to control medical practice, although it 
seems an insurmountable task to obtain it. 

When we see the good accomplished by vaccination, 
by quarantine against yellow fever and cholera, by anti- 
toxin in diphtheria, the lessening of typhoid by pure 
water-supply, the elimination of trichinosis by inspection 
of hog products, as done in Germany, and now the great 
awakening in regard to the prevention of tuberculosis, 
one must be impressed with the tremendous possibilities 
of preventive medicine. The realization of these possi- 
bilities depends upon the education of the people as to the 
dangers of disease, the cause of disease, and the practical 
method of prevention. 

The following officers were elected : President, Dr. 
Junius C. Hoag; vice-presidents, Drs. Henry B. Favill 
and Hugh T. Patrick; secretary, Dr. Arthur R. Edwards; 
treasurer, Dr. S. C. Plummer. 



OUR PHILADELPHIA LETTER 

[From Our Special Correspondent.] 

ANOTHER LEGAL SET-BACK FOR THE ANTIVACCINA- 
TIONISTS — THE ' 'KISSING-BUG" EPIDEMIC — THE 
SALE OF "EMBALMED" MI LK — DIPHTH ERI A AND 
THE FACTORY INSPECTORS— TUBERCULOSIS IN CAT- 
TLE—MEDICAL SOCIETY OF NEW J ERSEY— SMALL- 
POX IN PENNSYLVANIA. 

PHILADELPHIA, July 3, 1899. 
Still again has the antivaccinationist resorted to the 
courts to contest the constitutionality of the compulsory 
vaccination law. as applied to public-school pupils, and 
again has the opinion of the law defeated his intentions. 
The petition of a Mr. Charles J. Field of this city, aimed 
against the vaccination law as it now e.xists here, has 
been defeated, and the outcome gives satisfaction to every 
citizen of intelligence, lay and professional. The com- 
plainant filed a petition requiring reason to be shown why 
his daughter should not be admitted to a public school by 
its principal, who had refused to admit her because she 
failed to produce the proper certificate from a physician 
showing that she had either been successfully vaccinated 
or that she had at one time suffered from smallpox. In 
answer to the petition the City Solicitor filed an answer 
upholding the principal of the school, stating that the de- 
fendant was compelled to comply with the law passed in 
1895 relating to this question, and further, that the prin- 
cipal had to comply with a similar rule of the Board of 
Education. Thus another attempt to overthrow the com- 
pulsory vaccination law has been defeated in its incipi- 
ency, as has been the fate of all such attempts against 
this established prophylactic measure. But the incident 
proves that primitive mental receptivity still prevails in 
some quarters, and that lovers of right and of enlighten- 



ment must be on their guard to abort these attacks upon 
common sense, proven safeguards of the community's 
health. 

That annoying insect popularly known as the "kissing- 
bug, " which has been epidemic recently in Washington 
and Brooklyn, has visited Philadelphia, in tne course of its 
peregrinations northward, its presence here having be- 
come very evident by reason of the dozens of persons 
who have suffered from its bite during the past three or 
four days. Tne bites of this insect, which usually occur 
on the lips of the individual attacked — hence the name, 
•■kissing-bug"— are quickly followed by extensive swell- 
ing of the part, which becomes red and inflamed, and 
exceedingly sensitive. Signs of active cellulitis arc often 
present, and the lips swell to two or three times their 
normal size, so that articulation and eating may be im- 
possible The process subsides rapidly after forty-eight 
to seventy-two-hours' duration. The exact ideniny of 
the insect concerned in this epidemic is somewhat in 
doubt, but it is thought to be one of the varieties of the 
so called "assassin bugs," probably the opi^coetus per- 
sonatus. which is a common parasite of the ordinary bed- 
bug and housefly. It is an insect nearly an inch in 
length, of dark, brownish-red color, and having six legs 
and long aniennas. During the past week more ti an a 
dozen persons have applied for hospital treatment o 1 ac- 
count of its bites, and according to current reports the 
list of its victims continues to increase from day to day. 

"Embalmed milk," as it has been termed by those of 
facetious turn of mind is just now giving the inspectors 
of the Board of Health all sorts of worry, and extensive 
searches and tests are being carried on, to detect the 
presence and to suppress the use of this deleterious prepa- 
ration. "Embalmed milk" is nothing more nor less than 
milk to which formaldehyd has been added to prevent 
souring, and it is claimed that its use is fast becoming 
general, particularly in the poorer sections of the ciiy, 
among dealers with whom cheapness, and not quality, is 
the prime object of trade. The very minute propor- 
tion of formaldehyd required to prevent fermentation 
of milk, and the difficulty with which it may be de- 
tected by the ordinary methods employed in milk- 
testmg make its detection a rather elaborate chemical 
analysis, and decrease the chances of its being suppressed. 
Philadelphia has recently had quite an extensive assort- 
ment of other food adulterations, in addition to this form, 
the authorities having brought to notice a number of other 
instances relating to the adulteration of coffee, vinegar, 
and cider. What with fever-germed Schuylkill water 
and formaldehyded milk and salicylated beer, the poor 
inhabitant must needs altogether abandon liquid indul- 
gences unless his immunity happens to be absolute. 

The discovery this week of diphtheria in a "sweat- 
shop," by one of the State factory inspectors, is a rather 
disturbing incident which calls for increased vigilance and 
thoroughness in the inspection of premises where clothing 
and other articles of general sale are manufactured. 
Thanks to a new law, the authorities were able to take 
ptompt and radical measures in the present instance, by 
seizing and confiscating all the clothing found in the 



54 



OUR LONDON LETTER. 



[Medical News 



place. By the present plan of cooperation between the 
factory inspectors and the health-office of this city, it is 
believed that the dangers of the spread of infectious dis- 
eases from such foci will be at once minimized. 

Dr. Leonard Pearson, the State Veterinarian, has 
stated in his annual report, just rendered to the State 
Live Stock Sanitary Board, that durmg the past year 
one thousand cattle in this State were condemned as tu- 
berculous and killed, their value being appraised at over 
twenty -five thousand dollars. Dr. Pearson also reports 
an outbreak of anthrax in Jefferson County, and several 
cases of rabies in different parts of the State. The ex- 
cellent work of Dr. Pearson will be carried on this year 
unhampered by deficient appropriations, as it has been 
arranged that a sum of $40,000 shall be set aside for the 
expenses of the board during the fiscal year. 

The 133d annual meeting of the Medical Society of 
New Jersey was held at Allenhurst, June 27th, 28th and 
29th, the president of the society. Dr. Fisher, presiding. 
More than 1 50 delegates from the different county socie- 
ties were present, and the meeting was very successful, 
both as to the scientific matter discussed and the business 
transacted. The society elected officers for the ensuing 
year as follows: President, Dr. L. M. Halsey; vice- 
presidents, Drs. Wm. Pierson, John D. McGill, and E. 
L. B. Godfrey; secretary. Dr. E. W. Hedges; corre- 
sponding secretary. Dr. VVm. J. Chandler, and treasurer. 
Dr. Archibald Mercer. The next meeting will be held 
at Atlantic City in June, 1900. 

That smallpox prevails to a wide extent in Pennsyl- 
vania is shown by the last report of Dr. Benjamin Lee, 
secretary of the State Board of Health. This report, 
dated June 27th, states that no less than 146 cases of 
this disease have been reported since June 3d. Of this 
number forty cases occurred in Philadelphia. The ma- 
jority occurred in the western counties. 



OUR LONDON LE TTER. 

LFrom Our Special Correspondent.] 

NO DECISION YET IN THE HUNTER CASE — THE ENG- 
LISH CANCER SOCIETY AND ITS VIEWS ON PRE- 
VENTION — THE HARLEIN GOLD MEDAL TO LORD 
LISTER — HAFFKINE'S ADDRESS ON INOCULATION 
IN THE PLAGUE — LAWSON TAIT — SANITARY CON- 
DITION OF LONDON — THE PROGRESSIVE LIVER- 
POOL SCHOOL OF TROPICAL MEDICINE. 

London, June 24, 1899. 
The General Medical Council has not yet reported its 
decision in the Hunter case, to which I have already re- 
ferred, though that redoubtable warrior Victor Horsley is 
pushing the battle to the very gates. Its committee, of 
which Dr. Glover is chairman, reported in favor of the 
organization of a Conciliatory Board, which should medi- 
ate between the profession and the friendly societies and 
clubs in the serious clashes which are continually occur- 
ring. The council mildly approved of the theory of the 
report, but immediately thereafter emphatically refused 
to take any share in the formation of such a body, so 
"conciliation' seems as far away as ever. The council 
seems to continue in the same conservative frame of mind 



noted last week, as it flatly vetoed a proposition to increase 
the direct representation of the profession at large at its 
board by so much as a single member. 

There is abundance of sporting enthusiasm in the Eng- 
lish profession, and a fine healthy spirit it is. The 
"medical" dog-show, arranged by the Women's Medical 
School, proved a great success, attracting entries of 
nearly 250 dogs owned by members of the profession, 
and netting a handsome sum for the laboratory fund of 
the school. Week before last one of the leading golf 
clubs was the scene of a "medical tournament" which 
attracted much attention and many entries. And as 
every one whose early education has not been neglected 
knows, the championcricketer of England, the uncrowned 
king of the athletic world. Dr. W. G. Grace, is one of us, 
not merely in name, but in fact. He has a large practice 
to which he devotes himself in the winter, turning it over 
to a partner for the summer, when the cricket season be- 
gins. And so far from injuring his practice, his fame as 
a batsman is said to be a decided advantage to him pro- 
fessionally, and his patients are immensely proud of his 
prowess. Oddly enough, by the way, the honors in the 
golf tournament were won by a "Dr. Jekyll," though 
whether "Mr. Hyde" appeared in the competition is not 
stated. 

And after consumption, cancer. The English Cancer 
Society has just held its inaugural meeting, at which the 
usual melodramatic statistics showing an enormous in- 
crease were quoted and all true Britons urged to rally for 
its prevention. As even the pathologists among us are 
still completely in the dark as to the cause of cancer, just 
what form measures of prevention are to take, is dis- 
tinctly hazy, but the society rises superior to such halting 
considerations. It demands elementary instruction in the 
schools in the laws of the prevention of cancer, and a 
Parliamentary Inquiry! This is the way to talk! Just 
let the disease understand that you're not going to stand 
any more nonsense, but are about to proceed to prohibit 
it by law, and threaten it with Parliamentary Inquiry, 
and like Davy Crockett's coon, it will "come down" at 
once. Prevention without knowing the cause is delicious ! 
It reminds one how the "Hunters of the Snark," accord- 
ing to Lewis Carroll, " threatened its life with a rail- 
road share." 

At the anniversary dinner of the Royal Institute of 
Public Health the Harlein gold medal was presented to 
Lord Lister, in recognition of his invaluable services not 
merely to surgery, but to State medicine and sanitary 
science. We regret to learn that Lord Lister is at present 
somewhat severely indisposed, but it is hoped the attack 
will prove of but short duration. No honors can be too 
great or too many for him while he is still with us. 

Professor Haffkine's address on "Inoculation in the 
Plague," before the Royal Society week before last was 
both interesting in itself and a high tribute to the impor- 
tance and value of medicine in the eyes of its sister 
sciences. Agreement was almost unanimous among the 
experts present after the address that Haffkine's resub 
compelled belief in the value and promise of his method. 
As many as 80,000 patients were inoculated in one place 



JULV 8, 1899] 



TRANSACTIONS OF FOREIGN SOCIETIES. 



55 



(Hubli) and the sick and death rates were enormously 
lowered among them as compared with the uninoculated. 
The method of attenuation is by cultivating the plague 
bacilli in the presence of weak solutions of carbolic acid 
or oil of mustard, only the toxins of the attenuated bacilli 
being used in inoculation. 

The inoculation has proved remarKably safe and in- 
nocuous, although its sensory effects were described by 
an immunized gentleman present at the session as "like 
fifteen vaccinations at once," and the natives are begin- 
ning to feel confidence in it, a most important tribute 
from the novelty-hating and cowardly Asiatic. 

In this connection it will be of some little personal in- 
terest to American surgeons to learn that the antiseptic, 
flour of mustard, used with such excellent results by 
many of them in their operation-preparations, on the 
recommendation of Roswell Park, has been found by 
Haffkine one of the most efficient germicides against even 
the virulent plague-bacilli. 

Bacteriology has just scored another'triumph in the 
service of man; this lime not by directly preventing or 
curing his diseases, but by what really amounts to the 
same thing — protecting his food-supply. Dr. Edington, 
Bacteriologist to Cape Colony, South Africa, whose in- 
teresting results in Texas fever were noted in a recent 
letter, announces the discovery of a parasitic fungus 
highly fatal to locusts and with which he has succeeded in 
almost clearing several farms and gardens of these pests. 

As you already know, Lawson Tait died suddenly at 
his home, on the Welsh coast, on June 13th in the fifty- 
fifth year of his age. No recital of his triumphs and his 
services to surgery is needed, for his name has been a 
household word in the entire English-speaking medical 
world for twenty years past. In spite of many eccentric- 
ities and even "defects of his virtues," Lawson Tait was a 
genius, a reformer of the fighting type, and sincerely de- 
voted to the interests of the profession — as he understood 
them. His work in abdominal surgery will remain a per- 
manent monument to his memory of which any man 
might be proud. The surprising thing is that he could 
have written his name so high at such an early age and 
in spite of what the French aptly term his "difficult" 
temperament. An Ishmaelite of the Ishmaelites, he 
fought and flouted both antisepsis and vivisection, and yet 
his superb results by purely aseptic methods did much 
to turn the current of professional thought in the direc- 
tion of this higher step. His curt reply to the German 
surgeon before the days of antisepsis who visited him, 
and asked the secret of his su-cess, "I keep my finger- 
nails clean, sir!" accompanied as it was by a glance at 
the " mourning"-tipped fingers of his visitor, will live as 
the aseptic theory in a nut-shell. 

The Anglo-American entente cordiale continues to 
flourish. Last week's British Medical Journal devoted 
an editorial to a notice and cordial commendation of the 
report of our Minnesota State Board of Health, and ex- 
pressed its regret that the multiplicity of health authori- 
ties in London prevents its sanitary system from even 
approaching the scientific uniformity and efficiency of the 
Minnesota plan. 



The sanitary situation in London is really becoming a 
serious one. From time immemorial the world- capital 
has been divided, upon the most irrational of prin- 
ciples, into "parishes" based upon the area of influence 
of the great churches, each ruled by its "vestr^•," whose 
intelligence and progressiveness may be imagined, each 
of which was absolutely independent and practically re- 
sponsible to no higher power. Some thirty years ago 
these bodies made a sort of working-compromise, of the 
makeshift order, by appointing a Metropolitan Board of 
Works in whose care the streets, parks, and a few other 
universal interests were placed. About ten years ago 
this was further improved upon by the new London County 
Council, which has done yeoman service for sanitary re- 
form, but now Mr. Balfour's precious new London Local 
Government Bill proposes to relegate sanitary matters 
again to a lot of newly created "boroughs," so that the 
County Council has formally refused to take even badly 
needed sanitary steps, such as the appointment of addi- 
tional meat-inspectors, etc., on the ground that it does 
not feel justified in making any large expenditures on 
schemes which will be entirely upset in less than two 
years when the new boroughs come into power. 

Major Donald Ross began his lectures on the "Extir- 
pation of Malaria" at the Liverpool School of Tropical 
Medicine last week, and an investigation expedition is to 
start from this progressive little school no later than August 
for Sierra Leone on the west coast of Africa. Score 
another point for the superiority of private over govern- 
ment enterprise! Indeed the word seems a mockery in 
its last connection. The London Government School 
still "expects" to be open in October, although half the 
staff of its hospital has resigned on account of discourt- 
eous and dishonorable treatment. 

The Commission of Experts appointed by the govern- 
ment has completely disposed of the silly charges 
against the milk from the Aldershot sewage farm which, 
as we intimated in a former letter, rose solely out of the 
jealousy of competing local dairymen. 



TRANSACTIONS OF FOREIGN SOCIETIES. 

British. 

COLOTOMY FOR MEMBRANOUS COLITIS — TREATMENT 
OF ABSCESS IN THE ANTRUM — HEMORRHAGIC ERY- 
THEMA IN A CASE OF BRIGHT'S DISEASE— REMOVAL 
OF SUBCLAVIAN ANEURISM — TREATMENT OF GON- 
ORRHEAL SALPINGITIS — DECLINE OF TYPHOID 
FEVER IN THE NETHERLANDS. 

At the Clinical Society of London, May 12th, White 
and GOLDING Bird contributed a paper on right colot- 
omy for chronic colitis, the object of the operation being 
to give the colon perfect rest. Three cases were men- 
tioned, the first that of a lady, aged thirty-six years, who 
had had membranous colitis for twenty years. She was 
wasted, a complete invalid, and almost unable to take 
food, or any exercise. Right lumbar colotomy was per- 
formed in two stages, with a six-day interval, and the 
fistula allowed to remain open for a year. Six months 
after its closure the patient was perfectly well, eating or- 
dinary food, and taking out-of-door exercise. Two other 



56 



TRANSACTIONS OF FOREIGN SOCIETIES. 



[Medical News 



more recent cases were reported, in which right lumbar 
colotomy was performed with excellent result. The fis- 
tulas were still open. Right-sided colotomy was there- 
fore recommended for : ( i ) intractable membranous colitis ; 
(2) all forms of chronic ulceration of the colon that had 
resisted medical treatment, and which were obviously 
otherwise incurable. Most cases of very chronic dysen- 
tery were probably to be cured without colotomy. (3) 
Cases of idiopathic dilatation of the colon. The colotomy 
must be nght-sided, and colotomy is preferable to 
cecotomy, (or when the latter operation was done fluid 
feces escaped from the artificial anus, and this gave rise 
to much trouble ; while, further, it was difficult to prevent 
some feces passing on into the colon. More experience 
is needed to determine the length of time which the bowel 
should be left open, but certainly six months should be 
the minimum. 

Thomson mentioned a case of empyema of the max- 
illary sinus which had existed for two and possibly for 
seven years, and which had been completely cured in 
eight weeks by drainage through a tooth-socket. A drill 
was used to open the sinus, and a drain was employed. 
The only other treatment was a daily washing with an 
alkaline antiseptic solution. This simple method of treat- 
ment, first employed by Cowper more than 200 years ago, 
has lately been described as futile in long-standing cases. 

OvELL and Eve said that the simpler operation should 
be tried first ; but that in a minority of the cases it was 
unsuccessful on account of the polypoid growths in the 
antrum. In such cases treatment consisted in freely 
opening the antrum through the canine fossa so that the 
cavity could be inspected and the growths removed; and 
in two instances a counter opening was made through the 
inner wall of the antrum at the level of the floor of the in- 
ferior meatus. The cavity was first packed with iodoform 
gauze, and afterward treated with antiseptic irrigation. 
All of the patients that had been so treated by them had 
been cured except one, and he had been greatly benefited. 
They also reported a case of malignant disease of the an- 
trum, in which suppuration was the only symptom noted, 
and in which the presence of a tumor in the antrum was 
not suspected until the opening had been made through 
the bone. Subsequently the superior maxilla was suc- 
cessfully removed. 

May 26th, Fox related an instance of hemorrhagic 
erythema in a case of Bright's disease. The patient, a 
woman, aged sixty-one years, suffered from an acute 
trouble supervening upon a long-standing affection of the 
kidneys. The hemorrhagic symptoms referred to were : 
injected and swollen fauces, some erythematous maculae 
on the face and a few petechias on the legs. Five days 
later a generalized eruption of a macular type made its 
appearance. The macules were slightly raised, with a 
tendency toward rapid centrifugal extension. Their size 
varied from that of a pin-point to a diameter of half an 
inch or more. They soon became confluent. The color 
was a vivid red, not affected by pressure. The older le- 
sions had purple borders and bluish-red centers. The hands 
and feet of the patent were edematous, and the affection 
looked like a severe purpura. Later the lips were swollen 



and blood stained, and there were a few spots on the 
gums. The lesions became increasingly hemorrhagic 
and the patient died seven days after the general eruption 
began. The trachea, bronchi, stomach, and colon were 
intensely injected, and in the small intestine there were, 
besides, numerous hemorrhagic areas. The kidneys were 
small and granular. No micro-organisms were discov- 
ered. The eruption was thought to correspond clinically 
with the roseola of Willan. rather than with erythema 
multiforme. The speaker's experience with eruptions in 
nephritis led him to look upon them as heralds of ap- 
proaching death. They were either of the type of Willan 
or morbilliform in character. 

.^LLINGHAM reported a case of aneurism of the right 
subclavian artery. The vessel was ligated in its first por- 
tion, and thirty-eight days afterward the aneurism was 
successfully removed. The patient recovered good use 
of the arm, although two-thirds of the clavicle had been 
taken away. It was interesting to observe that pulsation 
returned in the radial artery within twelve days of the 
time of ligature. Hence the importance of removal of 
the sac in these cases. 

Duckworth said that he was treating a similar case 
in which he had considered operation, but postponed it 
in order to try the effects of rest, restricted diet, and 
iodid of potash. The aneurism was consolidating and 
shrinking, so that it seemed still unnecessary to perform 
an operation. 

Symonds mentioned a case in which he had attempted 
to ligate the first portion without removing the clavicle. On 
passing the needle under the vessel alarming hemorrhage 
was produced. When the needle was withdrawn the 
bleeding ceased. He therefore tied the innominate and 
common carotid simultaneously. So far the patient had 
done well. 

At the British Gynecological Society, May iith, Tay- 
lor read a paper on the treatment of gonorrheal salpin- 
gitis. A large number of women who are suffering from 
tubal disease have been at some time or another exposed 
to the infection of syphilis as well as of gonorrhea; and 
they undoubtedly show marked improvement after a pro- 
longed course of mercury and iodids, and in the course 
of this treatment, unless acute pyosalpinx intervenes it is 
the rule for all gross physical signs of disease to slowly 
and permanently disappear. Acute pyosalpinx is pecu- 
liarly liable to occur on the left side of the body, prob- 
ably as a result of secondary infection from the rectum. 
Such cases, whenever possible, should be treated by free 
incision of the posterior vaginal fornix, by thorough ex- 
ploration and emptying of all pus-cavities from the pouch 
of Douglas, and by iodoform-gauze drainage. The older 
operation of removal of the appendage- is not only much 
more dangerous, but is peculiarly liable to be followed by 
fecal fistula and operation-sequel sometimes worse than 
death itself. If the recovery is not complete, relapses fol- 
lowing the operation should be followed by a course of 
specific treatment, the beneficial result of this being often 
immediately manifest when the wound tissues are un- 
healthy and the healing is delayed. Occlusion of the 
tubes and peritubal adhesions consequent on gonorrheal 



Julys, 1899] 



THE AMERICAN SURGICAL ASSOCIATION. 



57 



salpingitis have no direct specific causation, and must be 
regarded rather as secondary mechanical results of the 
local peritonitis, which has been caused by salpingitis. 
Their absorption and disappearance will not therefore be 
secured by the cure of the gonorrhea, and sterility may 
persist, although gonorrhea may be entirely eradicated 
from the system. In gonorrhea of the pelvis there will 
probably remain a residuum of intractable cases, particu- 
larly cases of complication with other diseases, such as 
fibroids of the uterus. In these cases, vaginal hysterec- 
tomy, with or without removal of the appendages, is not 
only the most rational operation in theory, but is pro- 
ductive of the best final results. 

At a meeting of the Epidemiological Society, held May 
19th, Saltet read a paper on typhoid fever in the 
Netherlands. He showed that while the general death- 
rate per 100.000 from all diseases had declined by 14 
per cent, since 1872, and that for tuberculous disease by 
16 per cent., that for typhoid fever had declined by 63 per 
cent. The mortality in the towns from typhoid fell 72 
per cent., while in the rural districts it had fallen only 60 
per cent. The improvements in sanitation seemed to him 
insufficient to account tor this great decline in the mor- 
tality in typhoid, while the decline m other diseases was 
far less. He suggested that the progress of medial science 
had far more to do with it than was generally admitted. 
This theory would explam the greater decrease in the 
urban centers, than in the rural districts, although the 
latter would naturally be freer from communication of in- 
fection, by the better medical facilities offered the inhabi- 
tants of the cities. 

NOTTER remarked that the stationary character of ihe 
population of the Netherlands would favor their acquisi- 
tion of a degree of immunity. In India the extreme sus- 
ceptibility of recently arrived Europeans is notorious 
while with each year of service there is a rapid increase in 
their power of resistance. 



SOCIETY PROCEEDINGS. 

THE AMERICAN SURGICAL ASSOCIATION. 

Abstract of the Proceedings of the Twentieth Annual 

Meeting, Held at Chicago, May ji, June I and 2, 

iSgg. 

The Association met in the Hall of the Chicago Med- 
ical Society, and was called to order by Dr. W. W. 
Keen of Philadelphia. PROFESSOR De Laskie Mil- 
ler of Chicago delivered an Address of Welcome, 
which was responded to by the President. Dr. Keen 
then delivered his address. He selected for his subject 
"The Technic of Laryngectomy." 

He began by saying that he has been ill satisfied with 
the usual trchnic of laryngectomy, and, as in a recent 
case, he adopted a method which rendered the operation 
one of simplicity, caused but little loss of blood and little 
shock, and avoided the danger of aspiration pneumonia, 
he ventured to bring it before the Association in the 
hope that it will be tested by others so as to determine 
its real value. Instead of being a very severe and dan- 



gerous operation, as it has hitherto been regarded, he 
hoped this will place it in the categoiy of safe operations. 

Nearly all authors, whether surgeons or laryngologists, 
speak of the operation as an extremely severe and dan- 
gerous one. and this view is warranted by its past high 
mortality. The causes of the mortality are chieHv : (a) 
Weakness of the patient by reason of the disease, the 
poor aeration of the blood, and the entrance of septic dis- 
charges from the diseased larynx into the lung before the 
operation; (b'\ shock, including hemorrhage during the 
operation, and (c) after the operation, septic pneu- 
monia, due to the aspiration of infected wound-fluids. 
This is the greatest danger of all. The sources of these 
wound-fluids are twofold: first, the tracheotomy wound, 
if, as IS usual, tracheotomy has been done ; and. secondly, 
the wound left by the removal of the larynx. These 
wound- fluids are usually infected from the food, the se- 
cretions of the mouth, and the packing by iodoform 
gauze which renders primary union impossible. 

While the method which he was about to describe does 
not obviate the weakness or any other unfavorable influence 
from the general condition of the patient prior to opera- 
tion, it minimizes the other causes of death, and espe- 
cially the possibility oi pneumonia. 

He could not claim originality for any one of the steps, 
for they have all been employed, he believed, by others. 
Thus Bardenhauer closed the communication between the 
trachea and the pharynx, but he only kept it closed until 
the wound became covered with granulations, and com- 
plications were no longer to be feared, say fourteen days. 
The communication was then reopened for the insertion 
of an artificial larynx. After adopting this method he 
had had four recoveries, while by the former method he 
had had four deaths. Cohen united the stump of the 
trachea to the skin, one of the most important improve- 
ments in the technic, since it prevents in a large measure 
the access of wound-fluids to the lungs. Other surgeons 
also have used the Trendelenburg posture, etc. But as a 
systematically planned operation, combining many ad- 
vantages, the present technic as a tout ensemble itiay be 
called original. 

1. The general preparation of the patient is the same 
as for any other operation. 

2. Preliminary Disinfection. — As in all cases about 
the mouth, nose, pharynx, and larynx a systematic at- 
tempt is made for two or three days beforehand to secure at 
least partial d sinfection. While partial disinfection is not 
as good as complete, yet the results in treatment of frac- 
tures of the base of the skull, in the extirpation of rectal 
tumors, etc., shows its great value. The teeth are very 
carefully cleansed by the toothbrush. If there are any 
old stumps of teeth present it is better that they should 
be extracted, and the operation deferred a few davs until 
these dental wounds heal. For two or three days be- 
fore operation every two hours, when the patient is 
awake, the mouth and each nostril is sprayed separately 
with a solution of boric acid, listerin, or both. 

3. Tracheotomy. — Nearly all authors recommend a 
tracheotomy, either as the first step cvf the operation or 
more frequently ten to fourteen days before operation. 



58 



THE AMERICAN SURGICAL ASSOCIATION. 



[Medical News 



In the few cases in which dyspnea is great the author 
would be disposed to do a tracheotomy, say two weeks 
before the laryngectomy ; not, however, with a view of 
preventing the entrance of blood and wound-fluids into 
the lungs by the introduction of a tampon cannula, but for 
the purpose of improving the general condition of the pa- 
tient. 

4. Posture. — The entire operation, after the trachea 
is invaded, is performed with the patient in the Trendel- 
enburg position. The speaker was persuaded that the 
majority of surgeons do not appreciate to its full the ad- 
vantages which this posture possesses in all operations 
about the upper air passages. As he had pointed out in 
a previous paper, he employs it in epithelioma of the lip, 
in extirpation, or other operations on the upper and lower 
jaw, in removal of the tongue, in cleft palate, in opera- 
tions on the tonsils and pharynx, and all similar opera- 
tions. Blood will not run up hill any more than water, 
hence, if the surgeon employs this posture in laryngec- 
tomy he avoids one of the chief reasons for tracheotomy 
and the employment of a tampon cannula. 

The disadvantages of tampon cannula are very great. 
Kocher, like himself, has lately dispensed with them en- 
tirely. The three most commonly used are those of 
Trendelenburg, Hahn, and Gerster. Of the three 
Gerster's is distinctly, in his opinion, the best. It can be 
more accurately adapted to larynges of varying sizes, and 
is much less likely to injure the parts either by undue 
pressure or by difficulty of introduction. 

5. Anesthesia. — This is carried out at first through the 
mouth, and is continued until the larynx or trachea is in- 
vaded. A large tracheotomy cannula (12 millimeters in 
diameter) is then introduced and held in place by disin- 
fected tapes tied around the neck. The inner tube of 
this cannula is removed and the metal tube of a Hahn 
cannula, which precisely fits it, introduced. A rubber tube 
connects this vi-ith the ordinary funnel for the administra- 
tion of chloroform. 

The essayist described the operation in detail, and then 
spoke at length regarding the after-treatment. The pa- 
tient is kept in the Trendelenburg position by placing a 
chair under the foot of the bed. This posture prevents 
any wound-fluids from running down (or rather up) into 
the lung. This position is to be maintained for one day. 
On the second day the bed is lowered to the horizontal 
plane. On the third day the patient is allowed to sit up 
in bed on a bed-rest ; on the fourth, to get out of bed 
and sit in a reclining chair, and on the fifth day he may 
walk about the room. 

For two days nutritive enemata only are to be used. 
After that a teaspoonful of liquid food is given, at first 
every half hour, always followed by a tablespoonful of 
sterile water to wash away any food that might possibly 
leak into the laryngeal wound. At the end of a week full 
diet as to quantity may be given, but no solid food is to be 
given until the tenth day. No catheter or esophageal 
tube is required. On the day after the operation the small 
gauze drain is to be removed. Half of the stitches may 
be taken out on tl;e fourth day, and the remainder on the 
sixth day. 



The only objection to this method which occurred to 
the author is that it absolutely precludes the use of any 
artificial larynx. But the possession of voice is nothing 
when compared with a speedy recovery and a greatly 
diminished danger of a fatal result. Rutsch believes such 
a larynx is very unsatisfactory. 

At the conclusion of the president's address a sym- 
posium on "The Surgery of the Spanish War" was taken 
up. The first paper was read by Dr. Nicholas Senn 
of Chicago, and was entitled, "The Firstaid Package in 
Military Surgery." He stated that two things were 
brought out clearly during the Graeco-Turkish War, 
namely, the value of a first-aid antiseptic occlusive dress- 
ing in the prevention of wound infection, and the im- 
portance of immediate immobilization of compound gun- 
shot fractures. He suggested the following first-aid 
package for field use and emergency work : Two pieces 
of lintin, a form of compressed cotton, four inches wide 
and sixteen inches long, sterilized and folded twice 
lengthwise ; a teaspoonful of borosalicylic powder in a 
small waxed aseptic envelope; between them a piece of 
sterile gauze, forty-four inches square, with two safety 
pins, folded to corresponding size with the lintin com- 
press; all of these articles wrapped in tin foil; two strips 
of rubber adhesive plaster an inch wide and eight inches 
long, the whole to be sewed in an impermeable canvas or 
linen cover. In using the package the powder is applied 
to the wound, the linten used as a compress being held 
in place by the strips of adhesive plaster, and the gauze 
bandage placed over it. If two wounds are to be dressed 
at the same time, as is usually the case in modern war- 
fare, the contents of the package are equally divided and 
used, which can be done without materially impairing 
the efficiency of the dressing. The slight hemorrhage in 
wounds inflicted by the small-caliber bullet will soon sat- 
urate a part of the dressing, which by evaporation will 
soon convert the antiseptic powder and the cotton into a 
dry antiseptic crust, the very best protection for the 
wound against infection. Many military surgeons have 
e.\pressed themselves recently as being opposed to the 
employment of the first-aid package by any one e.\cept 
medical men. This position the speaker thought will be 
found untenable during any great war, when the number 
of wounded would greatly exceed the working capacity 
of the limited number of surgeons. In summarizing the 
following conclusions were emphasized : 

1. First-aid packages are indispensable on the battle- 
field in modern warfare. 

2. The first-aid dressing mus': be sufficiently compact 
and light to be carried in the skirt of the uniform or on 
the inner surface of the cartridge or sword belt, so as to 
be of no inconvenience to the soldier or in conflict with 
military regulations. 

3. The Esmarch triangular bandage is of great value 
in the school of instruction, but in the first-aid package 
it is inferior to the gauze bandage. 

4. The first-aid dressing must be applied as soon as 
possible after the receipt of the injury, a part of the field 
service which can be safely entrusted to competent hos- 
pital-corps men. 



July S, 1899] 



THE AMERICAN SURGICAL ASSOCIATION. 



59 



5. The first-aid dressing, if employed behind the firing- 
line, should be applied without removal of the clothing 
over the injured part, and fastened to the surface of the 
skin with Strips of rubber adhesive plaster, the bandage 
being applied over and not under the clothing. 

6. The first-aid dressing must be dry, and should re- 
main so by dispensing with an impermeable cover over , 
it, so as not to interfere with free evaporation of the | 
wound secretion. 

7. The first-aid dressing should not be disturbed un- 
necessarily, but any defects should be corrected at the 
first dressing-station. 

A paper, entitled "The Battle-ship in War," was read [ 
by Dr. N. M. Ferebee, Medical Inspector of the 
United States Navy. Norfolk. Va. He described a mod- 
ern battle-ship, spoke of the preparations for, and the con- 
ditions during, war. He also narrated his experiences 
with modern rifle-bullets and with shells, and closed his I 
paper by detailing interesting cases. I 

"The Organization and Equipment of Military Field 
Hospitals" was the title of a paper read by Dr. Georce 
R. Fowler of Brooklyn. Under the head of organiza- 
tion the essayist dealt with executive offices, dispensary, 
property office, post-office, quartermaster's office, com- 
missary office, medical ward, surgical ward, operating- 
tent or pavilion, pathological and bacteriological depart- 
ments, cooking department, diet-kitchens, sanitary and 
disinfection departments. In referring to location and 
arrangement, he spoke of the importance of selecting a 
suitable site, and then dwelt upon soil, drainage, ar- 
rangement of the wards, sinks, and emphasized the im- 
portance of cremating garbage and typhoid e.xcreta. 

In referring to equipment, he spoke of tentage, pavil- 
ions, furniture, linen, medical supplies, anesthetics, 
antiseptics, instruments, sterilizers, operating tent furni- 
ture, ligature and suture materials, dressing materials, 
splint materials, and transportation facilities. Lastly, he 
dwelt at length upon the personnel, which comprises e.x- 
ecutive and administrative officers, professional staff, 
ward officers, operating-stall, ophthalmologist, aurist, 
and dentist. 

Dr. Ch.^rles B. Nancrede of Ann Arbor, Mich., 
followed with a paper on "The Effects of Modern Small- 
arm Projectiles as Shown by the Wounded of the Fifth 
Corps." Reports show that about 1400 wounded were 
cared for at the hospital with which he was connected, 
for nearly all of the injured in this corps who survived 
for twenty-four hours sooner or later passed through 
their hands, so that flesh wounds, and those of a day to 
a week or more, were observed. Flesh wounds were al- 
ways of a trivial nature, unless the ball became deformed 
by striking some e.xtraneous object or when stripping its 
mantle, as it sometimes did. This immunity enjoyed by 
the flesh wounds caused by Mauser and Krag balls re- 
suited, first, from the slight amount of contusion caused 
by the rapidly moving ball ; second, the aseptic condi- 
tion of the ball, and, third, the rarity of the carriage of 
fragments of clothing into the wound, as was not uncom- 
monly done by the forty-three-caliber Remington, brass- 
mantled balls. If maintained aseptic, the majority of 



fJesh wounds healed almost as if they had been incised 
wounds, not uncommonly cicatrizing under the primary 
field dressing made with the first-aid package. 

Contusions, or slight wounds of the great vessels lead- 
ing to so-calied traumatic aneurisms, or aseptic or septic 
sloughing of the vessels many days after the receipt of 
the wound, were far from uncommon. Thus, he saw 
one wounded subclavian where the patient survived over 
three weeks, to finally succumb to hemorrhage during an 
attempt to ligate the vessel, which was torn for a long 
distance. He also knew of another dying on the table 
some weeks after being wounded during an attempt to 
secure the same vessel. He tied the common femoral 
for wounds and assisted a colleague in securing another, 
days after the receipt of the injury. He tied one radial 
for secondary hemorrhage, and ordered the tying of an 
ulnar for ball injury several days after their division, and 
was compelled to amputate an arm after failing to secure 
a bleeding brachial in an apparently aseptic wound two 
weeks after the man had been shot. 

The greatest advance in military surgery on the battle- 
field in recent times is the first-aid packet, and the great- 
est boon conferred on the wounded soldier has been 
asepsis and antisepsis, because in the majority of in- 
stances rendering his injuries so painless and their com- 
plications so slight that even anesthetics no longer occupy 
the chief place as a blessing to the wounded, because 
comparatively rarely needed. 

Dr. M. H. Rich.^RDSON of Boston read a paper on 
"Appendicitis; Should Every Patient Be Operated upon 
as Soon as the Diagnosis of Appendicitis Is Made? Should 
the Appendi.x Be Removed in Everj' Case?" At the bed- 
side, in a specific case of appendiciti.":, there would be 
doubtless little difference of opinion among even those 
surgeons who seem to differ materially in the expression 
of their views. What one may describe as a severe case 
another may regard as a mild one ; what one may con- 
sider a hopeless infection, another only a desperate one, 
and so on. The conclusions arrived at are the result of 
experience in 904 cases, personally observed and treated, 
and of personal observation of many others in the practice 
of hospital colleagues. In 259 cases of operation in acute 
cases 72 patients died. Four of these deaths were in 
the hands of other surgeons. In 189 acute cases opera- 
tion was not performed: of these, 31 patients died. 

Many of these fatal cases were desperate ones. All 
were severe. The mortality in acute cases without oper- 
ation was fully 31 in 189 cases. In practically all of 
these fatal cases the patient was moribund and the case 
hopeless when first seen. 

The most important question is not whether to operate 
in appendicitis, but rather when to operate. In view of 
the great mortality after operation in severe cases ; of the 
disadvantages following the drainage necessary in septic 
cases, weakness of muscles, stretching of scars, hernias, 
and the like, the best time to operate is during the period 
of perfect health following the attack. In a large per- 
centage of acute cases recovery from the acute attack will 
take place, and operation can be safely performed through 
a small incision which will not weaken the abdominal 



6o 



AMERICAN SURGICAL ASSOCIATION. 



[Medical News 



wall. After the initial stage the question of intervention 
becomes more difficult when observed for the first time 
on the second, third, or fourth days. In severe cases 
the patient should be operated upon at once, unless he is 
improving so rapidly that there is a strong expectation of 
complete recovery. Intervention is still more strongly 
indicated if the symptoms are increasing in severity. 
Operation is indicated, too if the symptoms after marked 
improvement recur. In the consideration of symptoms 
after the early hours, the character and extent of pain, 
tenderness and rigidity are important as determining the 
width and depth of the area of infection. The constitu- 
tional signs are less reliable than the local; they may be 
deceptive guides. 

The chief objection to operating in every case is the 
danger of converting a localized into a general infection. 
If the patient is improving, with a successfully localized 
peritonitis of considerable extent, especially if centrally 
localized, as in the pelvis, operation should be postponed 
until intervention can be safely practised, because these 
cases, in the absence of general peritonitis, are the most 
dangerous ones. An attempt should always be made to 
remove the appendix whenever the peritoneal cavity is 
opened unless the patient's condition forbids prolonged 
search. In many cases of abscess with firm walls a 
slough will be found which on examination will prove to 
be a necrosed or exfoliated appendix. In such cases no 
subsequent operation for removal of the appendix will be 
necessary. If, after recovery from simple drainage in acute 
appendicitis, there is evidence of renewed appendicular 
trouble, the appendix should be removed, the scar of the 
original wound incised, and the wound carefully closed. 
The operation is especially desirable if there is hernia in 
the scar or even stretching or discomfort. Hernia of itself 
after all operations for acute appendicitis should be oper- 
ated upon if it causes discomfort or disability. In very 
rare instances there may be a recurrence of infection in 
the region of the ileocecal valve, even after removal of 
the appendix. 

The discussion on Dr. Richardson's paper was opened 
by Dr. John B. Deaver of Philadelphia who said that 
the paper had brought out many points on appendicitis 
about which an active warfare had been waged for some 
years. Upon the surgeon's individual decision at the bed- 
side often depends the life of the patient, and in every case 
the very points about which the paper dealt have to be 
faced and a decision made. As to the question : Should 
every patient be operated upon as soon as the diagnosis 
is made? his answer was yes, with two exceptions: 
first, in cases of acute active general peritonitis ; second, 
in collapse. Should the appendix be removed in every 
case of appendicitis? Yes, with the exception of those 
cases in vi'hich the bowel forming a part of the abscess 
wall has undergone necrotic changes rendering the bowel 
friable and apt to rupture during the necessary manipu- 
lation. 

Dr. Richardson had most wisely divided his first head- 
ing into two classes : those in which the diagnosis has 
been made in the early hours (and the speaker took it for 
granted that he meant within twenty-four houis), and 



those in which a diagnosis is made after this period of 
time had elapsed. In answer to the first question. Dr. 
Deaver asserted most emphatically that the early hours is 
the Ume par excellence for operation in this most serious 
of intra-abdominal affections, first, because practically all 
patients operated upon at this time get well, or at least 
give the lowest monaliiy. this mortality increasing with 
the interval between the onset of the attack and the time of 
operation. Thus, of i8 patients operated upon within the 
first twenty-four hours, only i died, a mortality of 5.5 per 
cent. In 30 acute cases, on the other hand, in which the 
patients were operated upon within forty-eight hours, 10 
died, a mortality of 33 3 per cent. As far as his experi- 
ence goes, a careful examination of the statistics of acute 
cases convinces him that the local pathological changes 
reach by progressive stages their severest limit within the 
first forty-eight hours, and after that period the changes 
are more in the nature of sequela following the primary 
stage of infection. Second, the percentage of individuals 
that have one attack and then remain perfectly well and 
free from other attacks is very small. Of 460 in his own 
experience 312 had more than one attack. 

Should one operate when the diagnosis is made after 
the early hours, if the symptoms are severe? His experi- 
ence has led him to the belief that symptoms are very un- 
reliable and are not in proportion to, nor do they indicate 
the severity of. the pathological processes which are ta- 
king place in the belly. Many times he has opened the 
belly of a patient with a normal temperature, flat belly 
walls, and a quiet retentive stomach, in whom tenderness 
on deep pressure was the only sign of persistent trouble, and 
has found pus or a gangrenous and perforated appendix. 
The surgeon who waits in the case of appendicitis for the 
appearance of severe symptoms, or, worse yet, waits for 
an indication to operate until the symptoms increase in 
seventy will have many unnecessary deaths to his credit. 

Should the appendix be removed in the case of localized 
abscess with firm walls ' Success, under these circumstances 
depends upon the skill and the technic of the surgeon. The 
appendix should be removed, the only occasion for differ- 
ence of opinion being as to the time of its removal, i.e., 
at the primary operation or at a subsequent operation. 
If the appendix can be removed at the primary operation 
without additional risk to the patient, it seemed to the 
speaker that this is the time of election. That it can be 
done without additional risk has been repeatedly demon- 
strated, and in his own practice he does it in nearly all 
cases, because in 257 primary removals his death-rate in 
the past has been 167 per cent., and in 13 secondary re- 
movals the death-rate was 30.7 per cent. The reasons 
for the removal under these conditions are that surgeons 
do not subject their patients to the danger of an attack of 
acute appendicitis occurring before the secondary opera- 
tion. There is less likelihood of fistulas, either fecal or 
simple. The patient is cured with one operation instead of 
two, with the consequent saving of a variable period of 
invalidism. The appendix can hold but one of a few 
positions. It must be either post-cecal, pointing into the 
pelvis toward the spleen, or confined in the ileocolic, or 
subcecal, or ileocecal fossa. If it is embedded in exudate. 



July S 1899J 



THE AMERICAN SURGICAL ASSOCIATION. 



61 



the exudate itself will indicate its position. He agreed 
with the essayist as to the necessity of the ultimate re- 
moval of the appendi.x, differing from him only as to the 
length of time before the complete operation is per- 
formed. 

Dr. Christian Fenger of Chicago endorsed in the 
main nearly everything that Dr. Richardson had said. 
He, however, disagreed almost entirely with the views ex- 
pressed by Dr. Deaver. 

Dr. Francis B. Harrington of Boston thought 
there was very little difference of opinion between Dr. 
Richardson and Dr. Deaver. He said that Dr. Deaver 
did not operate in every case; he considers the condition 
of the patient. If the patient is in collapse, he waits, 
and so do all surgeons. It is better to wait not only in 
cases of collapse, but in other instances. He likes to re- 
move the appendix in every case in which it is possible to 
do so. On the other hand, there are certain conditions in 
which he is inclined to wait perhaps twelve or twenty-four 
hours, or even longer, before operating. 

Dr. Joseph Ransohoff of Cincinnati thought the 
doctrine advocated by Dr. Deaver would do a great deal 
of harm if followed by most men who operate upon pa- 
tients with appendicitis. An important point to remem- 
ber is that tive-sixths of the operations lor appendicitis are 
performed by general practitioners, men who have had 
very little experience in handling the intestines, in dealing 
with abscesses within the cavity of the abdomen, etc. 

Dr. Nicholas Senn of Chicago said that uniformity 
of practice in the treatment of appendicitis would proba- 
bly never prevail. Each man formulates his own indica- 
tions and follows his own rule of practice. Personally he 
felt weakest in making an early diagnosis in the first 
attack. 

•'Nephrectomy versus Nephrotomy" was the title of a 
paper by Dr. Joseph Ransohoff of Cincinnati, Ohio. 
He said that renal surgery is essentially the product of the 
past twenty years. The occasional operations on the 
kidney performed before that time paved the way for a 
clearer appreciation of the conditions demanding opera- 
tive relief. Improvements in the method of examination, 
and the consequently greater accuracy in diagnosis, the 
recognition of the early gross changes wrought by dis- 
ease, as seen by operation rather than by autopsy, and 
the comparative safely of incisions through healthy kid- 
ney tissue have brought to the fore the element of safe 
conservatism in the domain of renal surgery. Several in- 
teresting and instructive cases of pyonephrosis were re- 
ported. Nephrotomy, per se. is doubtless an operation 
nearly devoid of danger. When performed on a healthy 
kidney, as for slone, the mortality is less than 5 per cent. 
When performed lor suppurative diseases, the mortality 
rises. He had tabulated records of 78 nephrotomies for 
pyonephrosis exclusive of tuberculosis published within 
the last three years from various clinics. Of these 78 
nephrotomies, 17 were followed by death, a mortaliiy of 
21.8 per cent. In the hands of some surgeons the mor- 
tality has been very large. Four out of 5 cases were 
fatal in the Vienna clinic. Out of 5 cases of nephrotomy 
at the Roosevelt Hospital 3 patients died. On the othej. 



hand, Israel lost only i patient out of 8, and Thornton i 
out of 12. From the same sources he had tabulated 37 
primary nephrectomies with 9 deaths, giving a mortality 
of 24.3 per cent., and 17 secondary nephrectomies, with 
7 recoveries and 10 deaths, a mortality of 58.8 per cent. 
The advantages of nephrotomy for pyonephrosis are ob- 
vious . First, it is an operation readily tolerated even in 
patients greatly reduced by fever. Second, it permits the 
surgeon to determine the condition of the opposite kidney 
Third, by it the saving of even a small amount of function- 
ating kidney tissue may throw the balance in favor of re- 
covery. In dealing surgically with a pyonephrotic kidney, 
statistics can guide the operator only in a general way in 
the choice between nephrectomy and nephrotomy. Neph- 
rotomy is indicated in pyonephrosis, first, when the con- 
dition of the opposite kidney cannot be ascertained ; sec- 
ond, when the reduced condition of the patieni will not 
permit the major operation if this is indicated The 
nephrotomy is then but the prelim.nary step, to be fol- 
lowed by nephrectomy as speedily as possible. Third; 
when the operation reveals the presence of considerable 
kidney tissue, and an approach to the normal on the part 
of the pelvis and proximal portion of the ureter. Here a 
ureteroplasty may avert the need of nephrectomy. 
Fourth, when there is evidence or suspicion of disease in 
the other kidney. 

Primary nephrectomy is indicated, first, when there is 
a sound second kidney. Second, when inspection of the 
exposed kidney shows many or large pouches that can- 
not be successfully drained. Third, when there is a little 
kidney tissue left. Fourth, when an examination of the 
pelvis and proximal portion of the ureter makes it reason- 
ably certain that a return to the normal cannot take 
place. Fifth, in para- and perinephric suppurations 
where the kidney acts as a valve, impeding successful 
drainage. (Israel.) 

Dr. Francis B. Harrington of Boston then read 
a paper, entitled "Hernia Following Operations for Ap- 
pendicitis.'" He had made a personal examination of 
the condition of the abdominal wall in 236 cases of ap- 
pendicitis in which operation had been performed at the 
Massachusetts General Hospital by various surgeons. 
The subjects represented all varieties of the disease. The 
period which had elapsed since operation varied from 
nine months to nine years. No case was included in 
which operation had been performed since July, 1897. 
Total number examined, 236; males, 190: females, 46; 
27 true hernias in all — 1 1>< pei cent. ; 21 true hernias in 
males — ix per cent.; 6 true hernias in females — 13^^ 
per cent. Eighty-five wounds closed at the time of op- 
eration, 3 hernias, 3^ per cent. ; 85 wounds partly 
closed at the time of operation, 11 hernias, I2!2 per 
cent. ; 63 wounds left entirely open at the time of op- 
eration, 13 hernias, 20 per cent. If with these cases of 
true hernia are included 10 cases of punctiform hernia and 
53 cases of more or less bulging in the scar which did 
not constitute true hernia, the following percentage of 
weak scars is noted: in 85 closed wounds, 6 per cent. ; 
m 88 partly closed wounds, 51 per cent., and in 63 open 
wounds, 62 per cent. 



62 



DAS BECKEN. 



[Medical Nevtj 



An opening between muscles or tendons or both 
could be detected in the scars: In 85 closed at the time 
of operation, 26 per cent. ; in 88 partly closed at the 
time of operation. 83 per cent. ; and in 63 open wounds, 
87 per cent. There was general abdominal bulging in 
85 closed incisions, or 7 per cent. ; in 88 partly closed in 
cisions, 45 per cent., and in 63 open incisions, 46 per 
cent. During the period in which these patients were 
operated upon, that is, from 1888 to 1897, some of the 
muscles or tendons were cut at right angles to their 
fibers in the acute cases, and often in the cases in which 
the wound was tightly closed at the time of operation. 
The writer advocated the use of an enlarged McBurney 
incision in all acute cases, which obviates the cutting 
transversely of any muscle or aponeurosis. 

Dr. Albert V.-\nder Veer of Albany, N. Y., fol- 
lowed with a paper on "Some Unusual Cases of Appen- 
dicitis with Complications." Operative surgery, in its 
relation to the appendix, will ever present rare and un- 
usual cases. This was brought out strongly last year 
when the president of the Association and others de- 
tailed the histories of some very unusual lesions of the 
abdomen. Surgeons may examine their patients with 
ever so much skill, employing diagnostic intelli- 
gence to the best advantage, yet when they enter the 
peritoneal cavity they must be prepared for surprises. 
From the knowledge acquired from these isolated and 
rather rare cases it is more possible to increase the per- 
centage of recoveries. A hernial sac with the appendi.x 
therein is not particularly rare, but to find it with a for- 
eign substance like a pin, immediately in the appendix, 
and not having caused trouble, is somewhat unusual. To 
operate for the relief of femoral hernia and find not only 
the appendix, but a prolapsed bladder in the female, is 
certainly decidedly rare. The essayist then detailed eight 
somewhat unusual and complicated cases. 

Dr. Dudley P. Allen of Cleveland, Ohio, pre- 
sented a paper, entitled "Cases of Fracture of the Skull 
Followed by Recovery." He reported ten cases of frac- 
ture of the skull, all but one of them involving the base. 
The first five reported were fractures at the base of the 
skull without any injury to the vault. Of these, three of 
the individuals were rendered totally unconscious at the 
time of the accident, one was in a semiconscious condi- 
tion, and the third, so far as could be ascertained, re- 
tained co".sciousness. Bleeding from both ears occurred 
in two of these cases, whereas in three of the cases there 
was bleeding at only one ear. Deafness in one case oc 
curred in both ears at the time of injury. Whether in the 
other cases deafness occurred at the time of injury could 
not be definitely determmed. In two of these cases, 
however, deafness was complete and permanent in one 
ear, and in one case the hearing was much impaired in 
one ear. Loss of smell was complete in one case and 
greatly impaired in one case. Paralysis of one side of 
the face occurred in two cases, in one of which it re- 
mained permanent. These five patients with fracture 
confined to the base of the skull are alive and well at the 
present time, except lor the disabilities just described. 

There were two cases of children who fell from heights 



upon the vault of the skull, causing most extensive frac- 
ture and great deformity of the cranium. In one of 
these cases there was a great deal of hemorrhage from 
the ears. In both the scalp was lifted, the cranium was 
laid bare, and by means of a hook the fragments were 
raised to their normal positions. Both patients recovered. 
One, however, has impaired hearing in one ear. 

Two patients received injuries m the frontal region ex- 
tending mto the base. In one of these there was exten- 
sive injury to the frontal bone and a large amount of 
bone and considerable lacerated brain tissue was removed. 
There was a fracture in this case extending across above 
the frontal eminence to the temporal fossa, upon the op- 
posite side of the skull to that which received the greatest 
injury, and there was a fissure from the base of the skull 
extending from the frontal bone backward to the sella 
turcica. This patient had a large cerebral hernia. In 
the other case the injury to the frontal region and the in- 
volvement of bone was small. 

The point of interest in the latter case was the tem- 
perature, which rose gradually at two different periods to 
105° F.. the case presenting many of the symptoms of 
typhoid fever with relapse. The other characteristic 
symptoms of typhoid fever were, however, entirely lack- 
ing, and the presence of optic neuritis, indicating prob- 
ably a basal meningitis, placed the diagnosis of the cause 
of fever in considerable doubt. 

The tenth case was one of severe injury in the 
region of the right parietal bone, followed in some 
weeks by impairment of mental activity, and also 
of motion of the right arm and leg. This was found 
to be due to a large subdural collection of blood 
on the left side, notwithstanding there was no evidence 
of injury on that side. The accumulated blood amounted 
to several ounces. It was removed and the patient is 
now well. 

The following officers were elected for the ensuing 
year : President, Robert F. Weir of New York City ; first 
vice-president, Charles B. Nancrede of Ann Arbor, 
Michgan; second vice-president, Edmund Souchon of 
New Orleans, La. ; secretary. Herbert L. Burrell of Bos- 
ton; treasurer, George R. Fowler of Brooklyn, N. Y. ; 
recorder, De Forest Willard of Philadelphia; member of 
the council, W. W. Keen of Philadelphia. Place of 
meeting, Washington, D. C. , in conjunction with the 
Congress of Physicians and Surgeons; time. May i, 2, 
and 3, 1900. 

NOTABLE BOOKS. 



DAS BECKEN (THE PELVIS). VON 
WALDEYER.^ 



W. 



This work on the pelvis by one of the greatest living 
teachers and investigators of anatomy cannot fail to at- 
tract wide attention. The subject is an important one. 
A complete and accurate knowledge of the anatomy of 

' Das Becken. Topographtsch-anatomische mit besanderer 
berucksichtung der Chiryrgie und Gynakologie dargestellt von 
\V. Waldeyer, M.D., Ph.D., Professor der Medicin und Director 
derAnatom. Institute, Berlin. Boon: Fr. Cohen, 1S99. 



JULV S, 1899] 



REVIEWS. 



63 



the pelvis is essential not alone to obstetrics and gyne- 
cology, the topics first naturally thought of in this con- 
nection, but 10 the surgery of the rectum, the bladder, 
and the various lesions, so common in this region, of the 
bony and soft tissues. 

Though written by a professional anatomist, the book 
is far from being a dry digest of anatomical details; it 
gives in condensed and very practical form all the scien- 
tific medical knowledge we have up to the present time 
concerning not only the structures contained within the 
pelvis and their relations, but also its external coverings. 
This work is consequently a most useful one for the ma- 
terial it contains, and the method of its presentation is 
worthy of its contents. Original illustrations have been 
made from specimens furnished by such distinguished 
specialists as Testut of Lyons, Devy of Paris, Fritsch, 
Gusstrow, Nagel, Nitze, Olshausen, Krause of Berlin, 
von Recklinghausen of Strasburgh, Gerota of Bucharest, 
and others. Altogether, the book is one of the most 
notable medical books of recent years. 

Under the classification of pelves there is a very com- 
plete and suggestive discussion of the differences that 
have been noted, according to race, age, and sex, and 
the value of these peculiarities as regards ethnology and 
anthropology, as well as the more practical questions 
that sometimes come up for decision in medico-legal mat- 
ters. In the discussion of the shape of the pelvis atten- 
tention is called to the fact that it bears a definite, readily 
recognizable relation to the shapes of the heads of the 
races in which the different varieties occur. Sir William 
Turner's terms for their classification which are analogous 
to the corresponding cranial terms in anthropology are 
adopted. The Dolicho pellic. or long, oval pelvis, is 
found among the Australians, the Bushmen, the Hotten- 
tots, etc. ; the niesati pellic, or almost circular pelvis, 
among the Africans and the Tasmanians, and in New 
Caledonia and Melanesia; the plaiy pellic, or broad, 
oval pelvis, is found among the Europeans, the Mongo- 
lians, and the Indians. 

There is an excellent practical discussion of fractures 
and dislocations of the bones of the pelvis, and of tumors 
pertaining to this region both within and without the pel- 
vis. Under fractures there is a report of a case that was 
found recently in the anatomical rooms of the University 
of Berlin in which the anterior bladder-wall had been 
forced into the space between the two fractured ends of 
bone as they sprung apart during the application of the 
fracturing force, and was retained there by the resilient 
pressure of the bony arches after the violence had ceased 
to act. It is a complication whose occurrence has been 
suggested on theoretical grounds, but this is, we believe, 
the first actual case reported. 

Under the head of tumors external to the pelvis, comes 
the series of bursje that may in following a special trade 
or occupation become chronically enlarged in the pelvic 
region, or that may, after chronic enlargement has ex- 
isted for some time, become infected and suppurate. 
There is the organ-grinder's bursa, the bursa subcutanea 
trochanterica, situated just over the trochanter, and 
which becomes enlargad because of the irritation set up 



by the rubbing of the arm as it passes the hip in its fre- 
quent revolutions. There is the bursa subcutanea sacralis 
over the sacrum which enlarges in chimney-sweeps from 
the friction in ascending and descending chimneys. Then 
the bursa over the anterior superior iliac spines, which 
enlarges in weavers from the constant rep.'ated impact 
of the "throw" of the loom. In English it is customary 
to call the enlargement of the bursa; over the tubera 
ischiadica weaver's bottom (sometimes irreverendy re- 
ferred to by the medical student as student's bottom). 
Professor Waldeyer, however, reserves for this bursary 
enlargement over (or under) the ischiac tubercles the 
name of turner's (drechsler in German, /. c. , wood- 
turner or carver) bottom. 

With regard to the bladder and its relations to the 
ureter and kidney, some recent interesting work from 
various sources mutually confirmatory of certain newer 
views in this matter is given. The possibility of liquid 
being forced from the bladder into the ureter and thence 
to the pelvis of the kidney is admitted. Under patholog- 
ical conditions, as with an over- distended bladder, this is 
not so difficult to understand. But even with a not over- 
distended bladder, when that viscus is somewhat hyper- 
trophied, and its muscular fibers have been irritated into an 
easily excitable condition, liqui J may thus be forced back- 
ward in the urinary tract. In healthy animals this has 
been demonstrated experimentally a number of times, 
and by various observers. The importance of this can 
scarcely be overestimated, especially since we have of 
late learned that it takes but a comparatively slight 
amount of pressure in the renal pelvis above the general 
blood-pressure at the moment, to force the renal filter, 
and send back into the circulation excrementitious prod- 
ucts. 

With regard to the possibility of absorption in the 
bladder itself, Waldeyer rather leans to the view becom- 
ing so general of late that it does take place to a limited 
degree. He points to the spread of neoplasms along the 
vesicular-lymph channels as a confirmation of this view. 

He considers that though morphologically the posterior 
urethra and bladder are one, this portion of the urethra 
must not be thought part of the bladder in the urinary 
function. The internal sphincter of the bladder has been 
observed to be closed even under high pressure in the 
bladder of the living animal. Urine that finds its way 
into the posterior urethra is extruded completely by the 
micturition reflexes set up. There is an interesting dis- 
cussion of injections into the bladder by forcing the 
muscles of the anterior urethra. Rectal and uterine and 
vaginal tissues and functions are discussed in the same 
practical scientific manner. 



REVIEWS. 



The American Year-Book of Medicine and Sur- 
gery. Being a Yearly Digest of Scientific Progress 
and Authoritative Opinion in All BratKhes of Medicine 
and Surgery, Drawn from Journals, Monographs, and 
Text-Books, of the Leading American and Foreign Au- 
thors and Investigators. Collected and Arranged un- 



64 



THERAPEUTIC HINTS. 



[Medical News 



der the general editorial charge of George M. Gould, 

M.D. Illustrated. Philadelphia: VV. B. Saunders, 

1899. 

Since the initial appearance of this Year-Book of Med- 
icine and Surgery, in 1896, each succeeding volume has 
been received with even more favor than its predecessor. 
In these busy days it manifestly is impossible for the act- 
ive practitioner to glean his knowledge of the rapid 
progress along special lines from the multitudinous pub- 
lications issued for his benefit, and, therefore, it will be 
with a feeling of great satisfaction that he turns to this 
volume, in which he may find the facts boiled down and 
served with cleat and concise editorial comments which 
add greatly to their value. In a weekly journal it is im- 
possible to review in detail the many valuable features of 
a work of this magnitude; like all encyclopedias it must 
be studied by the individual in order that its many points 
of e.xcellence may be brought out. 

The data concerning typhoid fever and the Widal test 
is exceptionally complete. Regarding the latter the edi- 
tors of the section sum up by saying: "Statistics show 
beyond question that the serum-test gives a positive result, 
sooner or later, in practically all cases of typhoid infection, 
and a negative result in cases in which typhoid infection 
is not present, and has not existed in the patient exam- 
ined. . . Anolherfacl that must be recognized is, that the 
Widal reaction often fails during the first week of the dis- 
ease, and sometimes much longer. Repeated examina- 
tions are necessary in every case." Continued good re- 
sults from the Brand method are reported. The Wood- 
bridge treatment is condemned, and statistics presented 
to show that its claims to abort an attack are not deserv- 
ing of consideration. 

The advances made in the prophylaxis and treatment 
of pulmonary tuberculosis are reported in considerable de- 
tail. Work done in connection with the production of 
an antitoxin against yellow fever is reported, as well as 
improved methods in diagnosis and treatment. 

The review of the diseases of the stomach and intesti- 
nal tract is especially satisfactory. Under the caption, 
"Anesthesia," it is said that the records are strongly 
against the use of chloroform as a routine anesthetic. In 
22,219 chloroform-administrations there were 14 deaths, 
while in 17,067 administrations of ether, or gas and 
ether, there was i death. 

Halsted's method of intestinal anastomosis is graph- 
ically illustrated, as is that of Laplace. Modifications of 
the Murphy button are pictured and described. The 
X-ray in diagnosis is given a prominent place and all that 
is newest in connection with this invaluable agent re- 
corded. 

The remaining chapters are devoted to gynecology, 
pediatrics, pathology, nervous and mental diseases, or- 
thopedic surgery, ophthalmology, otology, diseases of the 
nose and larynx, cutaneous diseases and syphilis, mate- 
ria medica, physiology, legal medicine, public hygiene 
and preventive medicine, and physiological chemistry, 
and each covers the ground in a very complete and satis- 
factory manner. 

1 he book contains 1102 page?, is admirably indexed. 



Treatment of Eczema by Ointments Containing Sugar 

HOD.\RA of Constantinople uses for cases of moist ec- 
zema, impetigo, ecthyma, subnasal sycosis, and other 
skin diseases of vesicular or pustular nature, an oint- 
ment of zinc oxid and sulphur containing sugar, the des- 
iccative and keratoplastic properties of which he highly 
~ values. 
IJ Sacchari pulv. ] 



and has a number of full- page plates, some in colors, 
and numerous illustrations in the text. Taken all in all it 
is invaluable in the special field which it aims to cover 
and the busy practitioner cannot afford to be without it. 

Die Technik und der Comfort der Ernahrung. 
(Technical Methods of Conveniently Feeding 
THE Sick.) Von Dr. Martin Mendelsohn, Pri- 
vat-docent der inneren Medicin an der Universitat 
Berlin. Leipsic: George Thieme, 189S. 
The author of this little brochure, which is a reprint 
from Leyden's well-known work on the diet and feeding 
in disease, has written some interesting books on the tech- 
nics of nursing and other subjects, closely connected 
with the treatment of patients other than by drugs. The 
work under consideration deals with the proper prepara- 
tion of food for the sick and the manner of giving it to 
patients. The temperature of the nutritive material and 
methods of keeping it at any temperature, a discussion of 
dry, soft, fluid, and solid diets, a description of appara- 
tus for feeding the sick at any stage of convalescence, 
apparatus for changing the position of patients in bed, 
and a consideration of the patient's surroundings while 
eating are the topics which the author handles with evi- 
dent knowledge and certainly with skill. The little 
book contains much that is interesting and much that is 
valuable, and is well illustrated. 



THERAPEUTIC HINTS. 



Parts XX 



Parts X. 



Zinci oxidi 

Lanolini ( 

Vaselini J 

Sulphuris sublim. 

Glycerini 

M. Ft. unguentum. Sig. External use. 
For subnasal sycosis he advises continuous application 
of the ointment to affected parts of the upper lip, and in 
addition repeated swabbing of the nasal mucous mem- 
brane with a solution of silver nitrate, at first one per cent, 
gradually increased to four per cent. As improvement ad- 
vances the ointment may be used but once a day, but 
swabbing should be continued for a time after the cure is 
completed to avoid a relapse. Hodara has thus effected 
cures without epilation. 

For seborrheal eczema of a psoriaform type he pre- 
scribes as follows : 
]J Sacchari pulv. . . . Parts xx 

Chrysarobini .... Parts i-ii 

Glycerini ) „ . 

J ... I. aa Part X 



Parts XXX. 



Sulphuris sublim 

Lanolini / 

,, , . V aa . 

Vaselini ) 

M. Ft. utJguentum. Sig. External use. 



THE MEDICAL NEWS 

A WEEKLY JOURNAL OF MEDICAL SCIENCE. 



Vol. LXXV. 



New York, Saturday, July 15, 1899. 



No. 



ORIGINAL ARTICLES. 



THE TR E ATMENT OF SUMMER D/ARRHEA IN 
INFANTS .' 

By HENRY DWIGHT CHAPIN, M.D., 

OF NEW YORK. 

The treatment of summer diarrhea in infants 
naturally may be considered in three parts: pre- 
ventive, dietetic, and medicinal. In order to ap 
preciate the importance of preventive management 
it may be well to glance at some of the well-known 
causative factors that are in constant operation dur- 
ing warm weather. In the first place, all the varie- 
ties of diarrhea seen during the year are increased 
and aggravated in summer. The various mistakes 
so commonly seen in the feeding of infants take the 
front rank as causes. Gastric or intestinal indiges- 
tion usually precedes a diarrhea. Too frequent feed- 
ing, either at the breast or bottle, is a common 
underlying cause of infantile indigestion. When 
the bottle is used a larger amount of fluid than the 
infant's stomach can comfortably hold or digest is 
very often given. Cow's milk is not properly modi- 
fied to suit the infant's age and digestion in many 
cases, or various foods containing large amounts of 
starch or sugar are employed. With the advent of 
hot weather the various kinds of infantile indigestion 
are liable to take on a dangerous diarrheal form. 



an epidemic of summer diarrhea seems to be fairly 
constant. Some years ago Dr. Seibert, in studying 
this subject, showed that an epidemic would start 
when the average minimum temperature reached 
60° F. This condition begins in June and lasts 
through September, which are thus the dangerous 
months. The accompanying table shows the num- 
ber of deaths from diarrheal diseases in New York 
City during the past five years in children under five 
years of age, through the summer months, with the 
mean temperature of the corresponding periods. 

A glance at this table shows that July gives much 
the highest death-rate, and the average mean tem- 
perature of this month is from one to four degrees 
higher than August. The slight difference in tem- 
perature, however, is not sufficient to account for 
the much higher mortality. In 1895 it will be 
seen that the mean temperature of August was three 
degrees higher than July, which is most exceptional 
for summers in this latitude, and yet the mortality 
of July was 1084 against 633 for .August. The ex- 
planation is that after several weeks of warm weather 
the weaker babies die off. Hot weather usually be- 
gins late in May or early in June, so that by July 
there has been a month of fairly continuous heat. 
After several days of very great heat,the severe diar- 
rheas begin, often when the temperature has had a 
distinct and grateful fall. 



Deaths under Five Years. 





1894. 


1895. 


i8g6. 


1897. 


1898. 




Deaths. 


Mean 
Temp. 


Deaths. 


Mean 
Temp. 


Deaths. 


Mean 
Temp. 


Deaths. 


Mean 
Temp. 


Deaths. 


Mean 
Temp. 


June 


36: 
1 107 
499 

346 


70-41 
74-87 
70-57 
68.S1 


281 

1084 

643 

441 


72.S0 
72-50 
75.60 
70. So 


363 
S80 

564 
245 


6g.8o 
76.80 
76.10 
67.20 


220 
914 
446 
319 


67-45 
75-92 


157 
835 
650 

465 


7>-i5 

7605, 

75-33 
70.27 


July 

August 


September 



This is due to an acute fermentation or putrefaction 
of the gastrointestinal contents, with the consequent 
absorption of toxic substances which quickly induces 
grave, if not fatal, symptoms. The heat of summer 
first depresses the vitality and weakens the resisting 
power of the infant, and then induces subtle and 
dangerous changes in the cow's milk which is its 
common food. The degree of heat required to start 

^ Read at a general meeting of the New York Academy of Med- 
icine, June I, 1899. For discussion see page 87. 



When the baby feels the greatest depression from 
the heat the deleterious changes in the cow's milk 
are most marked, hence bottle-babies are by far the 
greatest sufferers. Not only does the lactic-acid fer- 
mentation begin, but various colonies of bacteria are 
multiplied, such as the saprophytes or those of the 
proteus group. Infants under two years are the 
greatest sufferers. Preventive treatment, if carried 
out with thought and thoroughness, will do much to 
alleviate this annual summer scourge. Such treat- 



66 



SUMMER DIARRHEA IN INFANTS. 



[Meuical News 



ment will include in ils scope an oversight of the 
city, the domicile, and the life and habits of the 
children. The responsibility of the city is to be 
doubly watchful in the interests of public health. 
The streets must be kept scrupulously clean. All 
garbage and decaying animal and vegetable matter 
should be promptly removed and destroyed. Perish- 
able food stuffs, and particularly cow's milk, re- 
quire careful watching and regulation. While milk 
with a certain minimum proportion of cream is now 
called for there should be a certain standard of 
freshness required as well. The number of bacteria 
found in each cubic centimeter of milk usually bears 
a direct ratio to the age of the milk. What is needed 
is a better regulation of a city's milk-supply at its 
source, namely, the dairy-farm. If the dairy farmer 
were compelled by government rules carefully laid 
down and enforced to regulate the production and 
handling of milk according to cleanly and scientific 
principles, and such milk could be delivered to the 
consumer within twelve hours, summer diarrhea in 
infants would be reduced to a minimum. In a city 
like New \'ork, which draws its milk -supply from 
such a wide area and from great distances, it would 
be difficult to devise a scheme of milk inspection on 
the lines above noted that would be practicable, but 
it is the goal to be sought for. If city infants 
could be supplied with a clean and fairly fresh milk, 
the illness and mortality from summer diarrhea 
would lessen in a very marked degree. In this con- 
nection it is interesting to note the report that the 
city of St. Paul now requires an official inspection 
of all cows from which the milk supply for that town 
is taken. 

.Another way in which the city can modify the 
deleterious effects of the heated term is by planting 
trees and furnishing small parks and breathing-places 
for infants and little children. In a thoughtful and 
suggestive article, entitled "Vegetation a Remedy 
for the Summer Heat of Cities," in the Popular 
Science Monthly for February, 1899, Dr. Stephen 
Smith shows how trees are of the greatest utilit)' in 
modifying and equalizing climatic conditions. He 
states that it is a well established fact that an aver- 
age temperature of the air of 5 4° F. is best adapted to 
public health, as at that temperature the decomposi- 
tion of animal and vegetable matter is slight, and 
normal temperature is most easily maintained. 
Every degree of temperature above or below this 
point requires an action of the heat-regulating power 
to maintain a proper equilibrium. As the heat-reg- 
ulating centers in infants and young children are 
most unstable, the direct action of prolonged heat 
upon their bodies is a powerful agent in increasing 
summer mortality from all kinds of illness. In a 



large and densely populated town the solar heat is 
conserved and reflected by the stone and asphalt of 
the streets as well as by the bricks and mortar of build- 
ings. The artificial heat generated in the latter for 
culinary and manufacturing purposes is also a factor 
to be considered. Even during the night the stones 
by retaining their heat prevent any fall in tempera- 
ture, sufficient to afford relief. Here is where the 
modifying effects of trees would be most beneficial. 
As trees maintain an average mean temperature of 
54° F. in all seasons, it is easy to see what a con- 
stant cooling influence they would possess in an at- 
mosphere of 90° F. Add to this the constant e.x- 
halation from the leaves of watery vapor that has 
been absorbed from the moisture in the soil as well 
as from the surrounding air, and the cooling effect 
is much enhanced. This takes place most actively 
during the heated portion of the day when it is most 
needed. A general purification of the air is not the 
least benefit to be derived from vegetation, as CO. 
is absorbed and O given out, just the reverse of what 
takes place in the animal economy. The purifying 
and cooling influence of trees placed uniformly 
through the city would have a marked influence 
upon the public health, especially that of little chil- 
dren. The Tree Planting Association of New York 
has proven that various species of trees are adapted 
to our soil, and, with a little care, can be made to 
thrive. It seems, however, in a matter that con- 
cerns not only the health but the beauty of the town, 
the city itself should be responsible for a imiform 
and continuous effort. If our blazing thoroughfares 
were lined with shade trees, the summer heat would 
not be so intolerable and unhealthful to adults and 
children alike. 

Much may be done in the domicile, to prevent 
diarrhea among the infant inmates. The principal 
efforts will be in the line of extra cleanliness. Food 
of all kinds must be removed when the meal is ended. 
Milk must be boiled or pasteurized as soon as it is 
delivered in the morning, then properly diluted or 
modified in bulk for the day and placed upon ice 
ready for use. The less it is handled after this the bet- 
ter. All diapers as soon as removed should be 
soaked in a solution of chlorid of lime or similar dis- 
infectant, before being washed. By keeping the 
rooms well closed during the heat of the day and 
freely aired at night, some equalization of tempera- 
ture will result. 

Preventive treatment can attain brilliant results in 
a watchful oversight of all the hygienic details of the 
infant's life. Mothers, particularly among the poor, 
should be taught to consult physicians oftener with 
reference to preventive agencies, especially when 
threatened by an epidemic of summer diarrhea. 



JULV IS. 1899] 



SUMMER DIARRHEA IN INFANTS. 



67 



Babies are often dressed too warmly and with need- 
lessly tight-fitting garments in summer. In very 
hot weather a single garment is often sufficient as it 
is comfortable and cooling to be able to freely move 
the arms and legs. Plenty of fresh air can be had 
early in the morning and late in the afternoon with- 
out exposing the infant to the heat of midday, even 
in the shade. While trips to the seaside are health- 
ful care must be exercised in reference to day 
excursions where heat and fatigue or slightly spoiled 
food may do more harm than the fresh air will do 
good. It is here assumed that the parents are una- 
ble to give the infants a change to the seaside or 
country, which, of course is highly desirable. In 
case a change of air is feasible for a bottle-baby, a 
locality where the milk-supply is known to be good 
must always have the preference. Frequent bathing 
is valuable in prophylaxis. In dispensary practice 
I often direct mothers to let little children be put in 
a tub and play in tepid water for several hours. 
Both the temperature of the air and that of the body 
are highest in summer from about two to five in the 
afternoon, and this is the time they are stripped 
and allowed to play in the water. The effects of the 
heat at the worst part of the day are thus neutralized. 
Babies too small for the tub may be sponged with 
water to which alcohol or vinegar has been added. 
In reference to diet very explicit directions must be 
given. In general, a bottle-baby should have less bulk 
of food and a higher dilution of milk in very hot 
weather than it is accustomed to under more favora 
ble conditions. If this simple precaution were taken 
much summer diarrhea would be avoided. The in- 
tervals between feedings may also be prolonged if 
the digestion shows any signs of derangement, but 
water is to be freely given during these intervals. 

With reference to milk, I prefer boiling or pas- 
teurization to sterilization. In case of prolonged 
and intense warm weather, sterilization may tempo- 
rarily be preferable. 

The final effort of preventive treatment is to note 
the first signs of gastric or intestinal indigestion, as 
both may often be checked by simple dietetic or 
medicinal means before a marked diarrhea begins. 

In the dietetic treatment of summer diarrhea, bear- 
ing in mind that a majority of the cases consist 
largely of milk-poisoning, all forms of milk must be 
temporarily withheld. Even the breast may be 
withdrawn in nursing babies until vomiting ceases. 
In the interval, water may be frequently given, but 
in small quantities at a time, if the stomach tends to 
reject it. The common mistake is in giving too 
much nourishment at this time, as the infant seems 
to be weak and in need of support. It is not the 
food taken, but that which is assimilated that sup- 



ports, hence it is folly to force milk upon a baby at a 
time when the digestive powers are weakened, if not 
entirely arrested. Many a summer diarrhea would 
be stopped at the very beginning if milk were en- 
tirely withheld for from twelve to forty-eight hours. 
When it is necessary to withhold milk for any length 
of time, other forms of nourishment may easily be 
substituted. One of the most easily procurable and 
satisfactory is egg-water. The white of an egg is 
thoroughly stirred in half a glass of cool water. This 
forms a pure and easily assimilable albumen water. 
The only objection is its tastelessness, and I have 
overcome this by the addition of about ten drops of 
aromatic spirits of ammonia. In case there is a 
tendency to vomit, this aromatic stimulant in small 
doses, as above, seems to check the stomach irrita- 
tion. Among other substitutes for milk may be 
mentioned thin gruels made from barley or wheat 
flour and cold whey. When the cereals are used, 
the starch may be easily dextrinized by one of the 
preparations of diastase that are now on the market. 
If cow's milk is withheld for several days or longer, 
mutton-broth from which all the fat has been care- 
fully skimmed, makes a good substitute. Expressed 
beef-juice with the fat removed and diluted with 
cool water makes a stimulating and nourishing drink. 
When the acute symptoms have subsided and milk 
is resumed, it must be tentatively begun at long in- 
tervals and with high dilution. If a prescription to 
be filled at a laboratory were written it might call 
for fat, I per cent.; sugar, 4 percent.; proteids, 
0.50 per cent.; or plain fresh milk may be diluted 
five or six times with sugar-water. By thus starting 
with a considerable reduction of the casein and fat, 
these solids may be gradually increased to a propor- 
tion that is proper for the infant's age and develop- 
ment. The diffi:ulty of digesting the tough curd of 
cow's milk is a constant source of trouble. After 
trying various methods of overcoming this difficulty, 
a proper dilution of the milk with decoctions of the 
cereals as advised many years ago by Jacobi, has 
yielded the best results in my hands. In hot 
weather a gruel made of wheat or barley flour, and 
partially or completely dextrinized, will modify and 
attenuate the clots of casein in a favorable manner. 
In a series of experiments recently made through the 
courtesy and with the cooperation of Professor Graham 
Lusk at his laboratory in the University Medical 
School, liquid rennet was added to various prepara- 
tions of milk and heated to 40' C. Equal parts of 
barley-water and milk gave smaller and more floccu- 
lent curds than equal parts of plain water and milk. 
A dog with gastric fistula was fed on consecutive 
days with these solutions, and the contents of the 
stomach withdrawn at the end of half an hour. The 



68 



HIGH ALTITUDE AND HEART DISEASE. 



[Medical News 



clots were finer and apparently more digested when 
the barley-water and milk was used than in the 
case of plain water and milk. Aside from the re- 
sults of such experiments, the clinical effect of di- 
luting with the gruels must commend their use. 
Babies are less apt to vomit tough, stringy curds, or 
to pass them by the bowel. 

The medicinal treatment usually assumes less im- 
portance in direct proportion as the preventive and 
dietetic management are carefully followed. Indis- 
criminate and abundant drugging in this disease are 
now relegated to the limbo of the past, astringents, 
antiseptics, and opiates alike. The real indications 
for drugs are few and easily apprehended. As sum- 
mer diarrhea is so apt to be of a putrefactive nature, 
all agree upon the necessity of completely clearing 
out the gastro-intestinal tract as a necessary start in 
treatment. In most cases, when the physician is 
called, the stools are loose and there may be vomit- 
ing. By at once stopping all milk, the stomach is 
soon emptied, and the principal indication is to clear 
out the bowel. If vomiting continues, drafts of 
tepid water may be administered, which, when re- 
jected by the stomach, washes out that organ. I 
do not believe it is often necessary to wash out the 
stomach with the tube. Sometimes when there is ex- 
cessive irritation of the stomach, with much produc- 
tion of mucus, one washing out, however, will give 
relief. I usually employ tablet triturates of calo- 
mel, -'- of a grain every hour until six or eight have 
been administered. These small doses act as a sort 
of stimulant to the bowel, increase glandular secre- 
tion and usually effectively clear the canal of its 
fermenting contents. The drug is also supposed to 
have some antifermentative effect. A good sized 
dose of castor oil is also effectual, and is followed by 
a sedative effect on the mucous membrane. If the 
stomach is very irritable, it may be difficult to ad- 
minister on account of vomiting. Elimination niav 
sometimes be hastened by irrigation of the lower 
bowel with normal salt solution. Mucus as well as 
fermenting milk may be thus removed. For those 
not accustomed to this procedure, a hard rubber 
rectal tube is preferable, as the soft tube bends on 
itself on account of the length and marked curve of 
the sigmoid flexure in infants. The drug that I 
have found most useful in the summer diarrhea of 
infants is the subnitrate of bismuth in large doses. 
As far as I have observed the subcarbonate, salicy- 
late, and subgallate of bismuth and beta naphthol bis- 
muth have no decided advantage over the subnitrate, 
which is everywhere procurable. A baby of from 
six to twelve months can take from ten to twenty 
grains of the subnitrate every two or three hours. 
The insoluble quality of the bismuth and its sedative 



local effect make it most valuable. Irritation and 
fermentation, even under proper dietetic manage- 
ment, remain longest in the ileum and colon and 
this tract is reached by the local action of the bismuth. 

Most of the so-called antiseptics have irritating 
qualities, and I do not think that even in antiseptic 
action they act better than large doses of bismuth. 
It is manifestly impossible to put the intestinal tract 
in any condition that can be called antiseptic by the 
administration of drugs. Small doses of aromatic 
spirits of ammonia, lo to 20 drops, well diluted 
with water, seem to stimulate the mucous mem- 
branes and refresh the infant. I give alcohol very 
sparingly in these cases as it seems to lower the 
digestive powers. In case of great weakness or 
collapse from 10 to 30 drops of whisky may be given 
well diluted. Formerly I gave whisky almost as a 
routine treatment in these summer diarrheas, but 
now it is used only for special indications and tem- 
porarily. If the discharges are profuse and exhausting 
and the baby sinks into a semi-stupor, with depressed 
fontanelle, very free stimulation by whisky and 
ammonia is indicated, as spurious hydrocephalus is 
thus ushered in. There is one drug that was for- 
merly much abused and is perhaps not used enough 
now in proper cases, namely, opium. It should 
never be given combined with other drugs; indeed, 
diarrhea mixtures of all kinds are to be deprecated. 
Opium is contraindicated until the bowel has been 
thoroughly emptied of irritating contents, when the 
stools are scanty and foul-smelling and when cerebral 
symptoms threaten. In cases, however, in which 
rapid peristalsis and profuse glandular secretion per- 
sist, a few moderate doses of opium are most valua- 
ble and may aid in saving life. 

The order of importance in treatment is that 
sketched in the preceding portion of this paper: 
first, prevention; second, careful dieting, and, 
finally, drug administration. If the first two are 
carefully carried out it will not so often be necessary 
to employ medicines. 



HIGH ALTITUDE AND HEART DISEASE.' 

By ROBERT H. BABCOCK, M.D., 

OF CHICAGO, ILL. 

My attention was first attracted to this subject 
years ago by the following interesting case: In No- 
vember, 1886, I was consulted by Dr. N., a prac- 
tising physician in the interior of New York State, 
who was on his return from Colorado. He was a 
powerfully built man of five feet nine inches in 
height, and 185 pounds in weight. U ntil October, 

■ Read at the fourteenth annual meeting of the American Cli- 
matological Association, held at New York, May 9, 10, and 11, 

iSgg. 



July 15, 1899] 



HIGH ALTITUDE AND HEART DISEASE. 



69 



1885, he had enjoyed robust health, and prided him- 
self on his strength and feats of physical endurance. 
He then one day carried a barrel of flour up stairs 
on his shoulders, and on reaching the top was seized 
with precordial pain and palpitation. From that 
time his health failed, a slight dry cough devel- 
oped, and once he expectorated a little blood. This 
led him to consult two eminent physicians of New 
York City, one of whom diagnosticated incipient 
tuberculosis of the right apex, while the other pro- 
nounced the examination negative. Both, however, 
advised him to go to Denver, which he did in June, 

1886. Upon reaching an altitude of 2000 feet en 
route he began to experience considerable distress 
in the chest, and on arriving at Denver, at an alti- 
tude of 5300 feet, he was almost, as he stated, in 
convulsions. During his six-weeks' stay his dysp- 
nea and precordial distress were so great that he at 
length consulted Dr. Dennison, who, he said, found 
his lungs normal, but demonstrated marked dilata- 
tion of the right ventricle. The advice was given 
to seek a lower altitude, and the patient went to 
South Dakota, where the elevation was but 1500 
feet. His symptoms gradually left him, and after a 
few days he was able to ride horseback without dis- 
comfort. 

This was about the middle of August, prior to his 
appearance at my office. My records, made after 
two examinations on successive days, state in brief 
that the lungs were normal, but that there was a 
short, rough presystolic and a faint blowing systolic 
apex murmur with accentuated pulmonic second 
sound and increase of dulness to the right. The 
pulse was somewhat accelerated, feeble, and slightly 
irregular. I made a diagnosis of mitral stenosis and 
insufficiency, either resulting from or aggravated by 
the unwise physical effort of the year before, and 
which accounted for the unexpected ill effect of 
high altitude. I have never heard from the patient 
since that time. 

Case H. is that of Dr. W. H. B., whom I first 
examined in February, 1887, making a diagnosis of 
fatty degeneration, chiefly of the left ventricle, due to 
coronary sclerosis and accompanied by attacks of 
angina pectoris. In November, 1887, he reported 
himself as well except for inability to walk rapidly 
on account of dyspnea. During the summer of 1889 
he made a trip to Alaska, concerning the advisabil- 
ity of which he had consulted me, and against which 
1 had urged the necessity of his being subjected to 
considerable risk in traveling over high mountains 
on the Canadian Pacific Railroad. Upon his re- 
turn, however, he reported that at an altitude of 
7000 feet he had been able to walk without any dis- 
comfort whatever. 



That serious structural disease existed is attested 
by the sad fact of his sudden death the following 
May, 1890, in an attack of angina pectoris at the 
age of seventy-three. No necropsy was made; but 
during life the somewhat thickened arteries and ac- 
centuated clapping aortic second sound had left no 
room for doubt of the existence of arteriosclerosis 
and resulting myocardial changes. 

Case HI. — About ten years ago one of my uncles, 
then seventy-two years of age, visited me en route 
to Denver to pass the summer. His radial arteries 
felt like a string of beads, and he had secondary 
left-ventricle hypertrophy, the heart still being com- 
petent. I greatly feared the effect of Denver alti- 
tude, and cautioned him accordingly; and yet he 
subsequently reported that while there he had been 
able to walk without the slightest inconvenience. Ifhe 
had noticed any effect from the altitude it had been 
for the better. 

Case IV., like the one immediately preceding, is 
reported from memory, as no notes were ever made. 
The late Dr. S. of Chicago, whom it was my priv- 
ilege to know intimately, once drew my attention to 
a loud mitral systolic murmur which he said he had 
had for years, but without particular symptoms. 
The circumstance that impressed my memory at the 
time was his comment to the effect that notwith- 
standing that murmur, which he regarded as indica- 
tive of valvular incompetence, he had just made a 
trip to Colorado Springs, an altitude of 6000 feet, 
and had been able to walk about with less discom- 
fort than his wife, who so far as he or anybody else 
knew possessed a healthy heart. This lady was 
rather short and inclined to corpulence, it may be 
remarked in passing. The doctor at that time was 
about sixty years of age. 

Case V. — H. P., aged twelve years, was seen in 
June, 1892, one month subsequent to an operation 
for appendicitis during convalescence from which 
anasarca and other signs of destroyed compensation 
of a long-standing mitral lesion had appeared. At the 
date of my visit digitalis and other appropriate treat - 
ment had begun to restore cardiac competence, and 
my opinion was desired upon the advisability of the 
boy's return to his home in Trinidad, Col. At the 
age of six years, while resident in that place, he had 
suffered from acute articular rheumatism, and then 
for the first time had been found to have a mitral 
lesion. During the next four years he had been in 
tolerable health, but had not been able to play with 
other children because of cardiac symptoms. Two 
years before my examination he had again suffered 
from rheumatism with pleuritis and pericarditis for 
which the precordia had been blistered. Neverthe- 
less, he had been able to remain at Trinidad, at an 



70 



HIGH ALTITUDE AND HEART DISEASE. 



[Medical News 



elevation of 6000 feet, until the development of the 
appendicitis. 

Upon examination I discovered mitral regurgita- 
tion with great secondary dilatation, pleuroperi- 
cardial adhesions, and old pleuritic adhesions at the 
base of both lungs, and great visceral engorgement. 
Of course the advice was given not to return to 
Trinidad, where his tuberculous father was residing. 
The patient passed the remainder of the summer of 
1892 in Canada, and I believe regained such a 
measure of compensation that during the fall of that 
year he was taken back to Colorado. I did not see 
the boy again, but have since learned indirectly that 
he failed progressively thereafter, and died about 
four months after his arrival there. 

Case VI. — During the summer of 1894 an attor- 
ney, aged forty years, consulted me for an opinion 
concerning the state of his heart, and, briefly stated, 
was found to have a pronounced but perfectly com- 
pensated insufficiency of the aortic valves. He 
furnished the following interesting histor)': He had 
but shortly before returned from a two-weeks' visit 
in Colorado, where at the altitude of Denver and 
Colorado Springs he had ridden about on his wheel 
without any discomfort. One day he attempted the 
ascent by train of Pike's Peak, which has an alti- 
tude of 14,137 feet. Distress became so great that 
he was in collapse by the time the summit was 
reached. The descent was made at once: his con- 
sciousness returned before he reached the foot, and 
when again at the altitude of Colorado Springs he 
mounted his bicycle and rode away, apparently none 
the worse for his foolhardy adventure. I have not 
seen the patient since my first examination. 

Case VII. — At the present writing I have in 
charge a lady aged about forty years, who has been 
in bed for the last four months in an attempt to pre- 
ser^e from total loss what still remains of a rather 
inadequate compensation of an extreme aortic steno- 
sis. She has known of her cardiac lesion for the 
past seven years. Although she had been cautioned 
against high altitudes she was compelled about five 
years ago to accompany a tuberculous stepson to 
New Mexico. At first they went to Colorado 
Springs, where they remained a month. There she 
was not able to walk more than a few hundred feet 
without sitting down to recover breath. For some 
reason they then went to Sante Fe, 7000 feet, but re- 
mained only two days because of the great distress oc- 
casioned to the lady. In consequence they next 
traveled to Eddy in the Pecos Valley, where she was 
able to stay until the young man's death, two years 
subsequently. While there, at an elevation of about 
3000 feet, the lady experienced no particular dis- 
comfort, being able to walk about the house and 



grounds without dyspnea. She is positive that she 
has never been as well since her sojourn in New 
Mexico, and in fact was compelled to seek medical 
advice for her cardiac asthenia soon thereafter. 

Case VIII. is that of a lady, aged sixty-eight 
years, who, immediately before consulting me, had 
endured the railway journey from San Francisco to 
Chicago over the Sierra Nevada and Rocky Moun- 
tains. At the summit of the former, 7500 feet, and 
again at Hagerman Pass, 11,500 feet, she sufiered 
considerably from difficulty in breathing, but at 
Colorado Springs she experienced no discomfort. 
Nevertheless, she thought it prudent to sit still in 
the car and not attempt walking. This patient had 
a pronounced mitral systolic murmur and great sec 
ondary cardiac dilatation, particularly of the right 
auricle, as shown by the turgid external jugular 
veins and by percussion. There was evidence also 
of arteriosclerosis; and as the pulsations of the thin- 
walled and probably dilated aorta were visible in 
the suprasternal fossa and communicated to the dis- 
tended veins, the erroneous diagnosis had been 
made of aortic aneurism. Rest in bed, aided by 
the administration of strophanthus and cathartics, 
lessened the cardiac dilatation markedly and more 
promptly than I had dared to hope for, and soon 
thereafter I lost sight of the patient. Six months 
later she died in charge of a homeopathist, who, I 
was told, said she developed an ovarian cyst. 

C.\SE IX — Last summer Miss N., aged twenty- 
one years, was referred to me by Dr. Minor of 
Asheville, N. C, because she had not been able to 
endure the 2500 feet altitude of Asheville, and had 
to return to her home in Chicago. She stated that 
she had been forced to leave there on account of 
the dyspnea experienced whenever she attempted to 
do any walking, although such had not been the 
case when there two years earlier. Examination dis- 
closed free mitral regurgitation, and in addition ex- 
tensive adhesions between the pericardium and left 
pleura, as shown by retracted lung border and fric- 
tion rales on inspiration. The apex was fixed in 
the sixth left interspace fiilly two inches outside of 
the mammar)- line. The right heart was not bound 
down. Hepatic and other visceral engorgement was 
extreme, and disappeared on appropriate treatment, 
with the lessening dilatation of the right ventricle. 
But the ready dilatability of the right heart has its 
bearing on the patient's inability to endure the mod- 
erate altitude of 2500 feet. 

Of course I realize that nine cases afford alto- 
gether too slender a basis on which to build a the- 
ory regarding the effect of high altitude on the 
heart and circulation, but they seem to me worth a 
few minutes study in the hope that they may aid us in 



July 15, 1899] 



HIGH ALTITUDE AND HEART DISEASE. 



71 



deciding the question whether or not the existence 
of heart disease always prohibits residence or travel 
in elevated regions. That such is the case is the 
general opinion, I think, an opinion in which I 
formerly concurred. 

Regnard, on the contrary, thinks that cardiac 
lesions /^A- se do not contraindicate sojourn at high 
elevations when such residence is necessary; yet he 
would not advise it because there is nothing in the 
condition of health of these patients demanding such 
climatic treatment, in fact, hematosis would be di- 
minished; but aside from this no harm would result 
from the decreased blood pressure; and if a cardiac 
sufferer chose to endure the discomfort he would 
at first experience until he became acclimated, he 
could do so with impunity. Regnard evidently 
bases his opinion on the study of the phenomena of 
mountain sickness which his experiments have led 
him to attribute not to diminution of blood pres- 
sure, but to want of sufficient oxygen supplied to 
the tissues and organs — "I'aspkyxie des tissus siirvi- 
ent." 

Although such may be the explanation of moun- 
tain sickness, I, nevertheless, think that Regnard's 
view regarding the effect, or rather, want of perma- 
nent effect on heart patients, is too sweeping, 
as some of my foregoing cases show. There is a 
quickening of the pulse-rate, and this it is which I 
think must be reckoned with in considering the 
question of altitude in cardiac disease. 

In an interesting paper in the London Lancet of 
October 15, 1898, Sunderland reports the arrest of 
menorrhagia at high altitude, 5800 feet, and sug- 
gests the explanation that by reason of diminished 
air pressure on the abdomen and in the lungs the 
large distensible veins within the peritoneal cavity 
become dilated, and thus favor a more rapid return 
flow of blood from the congested vessels within the 
pelvis. Unfortunately, this theory is untenable, 
since it must assume an expansion of the tissues in 
the walls and organs of the abdomen, and as Reg- 
nard argues, such an expansion of solids and fluids of 
the body is impossible when the entire surface of the 
body is subjected to uniform diminution of atmos- 
pheric pressure. It would be far otherwise if the 
vessels were filled with a gas instead of blood. 
Sunderland's explanation is correct only in part. 
The menorrhagia is arrested in consequence of more 
active circulation undoubtedly, yet this acceleration 
is not due to lessened blood pressure occasioned by 
essened air pressure, but I believe, to those modifi- 
cations of the respiratory movements incident to 
owered atmospheric pressure. 

According to Regnard the effect of high altitude 
is to quicken respirations at first and render them 



more shallow. When, however, the individual has 
become accustomed to the diminution of air pressure, 
the depth of respiration increases and may even ex- 
ceed the average. That this increase in the depth 
and frequency of respiration must accelerate the 
blood- flow will become apparent upon consideration 
of the eftect of respiratory movements on the circu- 
lation. Briefly stated it may be said that with each 
inspiration pressure falls within the two vense cavfe 
in consequence of their contents being aspirated into 
the right auricle and ventricle. This latter cham- 
ber, therefore, receives and discharges an increased 
supply of blood into the pulmonary artery, while 
under the dilating influence of inspiratory expansion 
of the lungs the flow within the pulmonary vessels is 
hastened. The consequence is that toward the 
height of inspiration and during the fore part of ex- 
piration a larger volume of blood is discharged into 
the aorta and pressure within this vessel rises. Dur- 
ing the latter part of expiration and in the beginning 
of inspiration, on the contrary, the reverse obtains. 
If now respiratory movements be quickened and 
deepened, as at high altitudes, the rate of the heart's 
contractions must undergo a corresponding accelera- 
tion. 

Another tactor in hastening the flow of blood to 
the heart is the action of the diaphragm. Accord- 
ing to physiologists, the descent of this muscle by 
diminishing the size of the abdominal cavity causes 
an upward flow of blood out of the abdominal veins 
into the inferior vena cava and thus exerts a pump- 
ing action. It is evident, therefore, that herein 
lies another by no means insignificant explanation of 
the beneficial effect of the high altitude in Sunder- 
land's cases of menorrhagia. 

That an acceleration ot the circulation is not merely 
theoretic is substantiated by the statement of Reg- 
nard and others who declare that the pulse may 
reach even 130 or 140 beats to the minute. Fur- 
thermore, Regnard reproduces three sphygmographic 
tracings which show a diminution in the size as 
well as increase in the rate of the pulse at an eleva- 
tion of 1050 meters, while at the summit of Mont 
Blanc, 48 10 meters, the smallness of the pulse be- 
comes still more pronounced. Now this diminution 
of the pulse must be due either to engorgement and 
weakness of the right ventricle, in consequence of 
which it discharges an abnormally small volume of 
blood into the pulmonic system, or to the fact that 
the heart in its entirety handles a small amount of 
blood with each cardiac cycle. The former hypothe- 
sis is untenable, since it is at variance with the ef- 
fects observed in menorrhagia. Stasis in the right 
heart would have led ultimately to increased en- 
gorgement of the uterine veins and capillaries and 



72 



HIGH ALTITUDE AND HEART DISEASE. 



.Medical News 



thus have aggravated the condition. Therefore 
we must assume that the smallness of the pulse at 
the summit of Mont Blanc was owing to the rapidity 
of the cardiac contractions, while its diminution of 
tension was not due to dilatation of the arteries from 
lessened airpressure,but to the smallness of the blood- 
wave resulting from the rapidity of the heart-beats. 

Let us see how this simple explanation can be ap- 
plied to the foregoing nine cases. Cases II. and III. 
were instances of arteriosclerosis without valvular 
disease and in both arterial tension was consequently 
increased. This threw extra work upon the left 
ventricle, which in Case III. was adequately met by 
compensatory hypertrophy, while in Case II. the 
presumably degenerated myocardium was unequal to 
the task and dyspnea on exertion resulted. At 
7000 feet, however, the quickened return circula- 
tion in the veins relieved pressure in the arteries, 
the weakened left ventricle found its work easier in 
consequence.and the patient could walk about without 
discomfort. For the same reason the third patient 
was able to spend the summer in Denver without 
consciousness of any difference between the altitude 
there and that of Cleveland, where he resided. 

Cases IV. and VI. were instances of regurgitant dis- 
ease, the one mitral, the other aortic, and both pa- 
tients had experienced no difficulty from exercise at 
an altitude of about 6000 feet. The reason for this 
seems to me to lie partly in the diminution of arte- 
rial tension and partly in the relief felt by the left 
ventricle. Diminution of pulse tension would tend 
to lessen the force of the regurgitant stream in either 
case and thus lighten the work of the heart. In 
mitral incompetence the dilatation of the pulmonary 
vessels and quickening of the flow through them in- 
cident to deepened respirations would relieve the 
right heart, and it is conceivable that dyspnea 
might actually be lessened thereby. As in regurgi- 
tant lesions the tendency is for the pulse-rate to be 
quickened, the heart ought to find but little difficulty 
in adjusting itself to the acceleration of the venous 
flow occasioned by lowered atmospheric pressure, 
and I believe such is the case when complications 
do not prevent. 

In Case VIII. there was free mitral leakage with 
a greatly distended right auricle, and yet the old 
lady suffered from dyspnea and cerebral congestion 
only at altitudes considerably higher than that of 
Colorado Springs. This must have been owing to 
her remaining seated in the car, so that notwith- 
standing the more rapid flow into the right auricle 
the resistance in front was lessened, as already ex- 
plained, sufficiently to offset the increased discharge 
into the auricle. Had she attempted to walk about 
she would probably have felt very short of breath. 



Cases ^'. and IX. were likewise examples of mi- 
tral insufficiency, but complicated by pericardial and 
pleural adhesions. Here were conditions that would 
obviously interfere with pulmonary expansion, and 
would occasion dyspnea under lowering of air pres- 
sure even without the existence of a valvular defect. 
There was probably some increased play of the dia- 
phragm which promoted the flow in the inferior 
vena cava more rapidly than it could be disposed o( 
by the hampered heart. In the young lady's case 
the adhesions binding down the left ventricle re- 
stricted its systole, while at the same time the un- 
fettered right ventricle was free to receive and dis- 
charge its contents until the pulmonary system be- 
came surcharged and dyspnea resulted. In a word, 
pleural and pericardial adhesions furnish a mechanical 
hindrance to a proper adjustment ol both respira- 
tory and circulatory apparatus to a diminution of 
atmospheric pressure. 

Case I. was an instance of mitral stenosis and 
Case VII of aortic constriction. In both an un- 
yielding barrier to the blood flow existed, and time 
had to be allowed for the stream to pass the point of 
obstruction. In stenosis systole is slow and forcible 
so long as compensation is adequate. Acceleration 
of the circulation at high altitudes would quicken 
cardiac contractions; with the shortening of systole 
time would not be allowed for complete emptying 
of the chambers back of the constriction; stasis in 
the pulmonary vessels would be promoted with cor- 
responding dyspnea that might readily grow urgent 
on exercise. 

CONCLUSIONS. 

1. All forms of cardiac disease do not contrain- 
dicate sojourn at a high altitude. 

2. The ill efi"ects of low atmospheric pressure in 
some forms of cardiac disease are explicable on the 
hypothesis of acceleration of venous flow and corre- 
sponding quickening of the heart beats. 

3. Consequently those forms with which high 
altitude is likely to prove incompatible are pro- 
nounced aortic or mitral stenosis, and regurgitant 
disease complicated by pleural and pericardial ad- 
hesions. 

4. On the other hand, patients with uncompli- 
cated regurgitant lesions or arteriosclerosis with or 
without myocardial changes, may endure low atmos- 
pheric pressure without injury. 



Yellow Fever in Mexico and Central America. — The 
epidemic at Vera Cruz is still spreading, about fifty new 
cases being reported each week. The mortality has been 
high, averaging about 47 per cent. At Panama 34 cases 
have been reported, with 18 deaths. 



July 15, 1899J 



CYSTITIS; ITS CAUSE AND TREATMENT. 



CYSTITIS; ITS CAUSE AND T R E A T U E N T. 
By GEORGE T. HOWLAND, M.D., 

OF WASHINGTON, D. C. 

The different opinions that have been held, and 
continue to be held to a certain extent, as to the 
cause of cystitis, are many and varied. C. Monsell 
Moullin," in his very interesting work, speaks cor- 
rectly when he says, "It is better that the pecu- 
liarly misleading term, 'catarrhal cystitis' should be 
dropped." Melchior ' states that while he does not 
deny the possibility of the occurrence of catarrhal 
cystitis, so far he has never met with it. Guyon ^ 
expressly states that there is no variety of cystitis 
that is not purulent. Cohnheim* also states that 
pus is always present in the urine in cases of cys- 
titis, whether the inflammation is acute or chronic. 

That the starting-point in cystitis is due to an in- 
fection, and that the disease is continued by the 
action of one or more of the various pathogenic 
micro-organisms, may be said to be an axiom as far 
as this disease is concerned. The easiest avenue 
through which an infection may occur is through 
the urethra, in which normally a number of differ- 
ent organisms are constantly present. Most of these 
organisms are non-pathcgenic, but the colon bacillus 
is present in a very large proportion. It is still un- 
decided whether the deeper portions of the male 
urethra, if healthy, harbors pathogenic organisms 
for any length of time. When the urethra has been 
altered by stricture or by enlargement of the pros- 
tate the chances of pathogenic organisms being able 
to maintain themselves in it are greatly enhanced. 
In women who have borne many children, in whom 
the urethra is dilated and patulous, an infection may 
occur by the organisms passing into the bladder 
from the urethra without the aid of instruments. In 
women the neighborhood of the meatus urinarius is 
never free from micro-organisms, and cultures of 
the colon bacillus mixed with others can nearly al- 
ways be found. The bladder may also be infected 
from the kidney, either when the kidney or its pel- 
vis is diseased, as in pyelitis or pyelonephrosis, or 
even when the kidney is healthy the organisms may 
be eliminated from the body through it and thus in- 
fect the bladder. 

Reymond' has proven beyond any question that 
bacteria can enter the bladder direct from inflamma- 
tory areas in the neighboring organs. He found 
cystitis of frequent occurrence in women suffering 
from inflammation of the uterus or of the Fallopian 
tubes and in the majority of cases proved by culture 

1 "Inflammation of the Bladder," p. 22. 189S. 
^ •Cystite et Infection Urinaire," Paris, p. 342, 1895. 
' "Lemons Cliniques sur les Affection Chir. de la \'essie el la 
Pfostate," Paris, p. 611, 1SS8. 
* Vorles. u. AUg. Path., Leipsig, 1880. 
^Ann. des. Mai. des Organes Gen. Crin., Paris, .^pril. 1893. 



that the organisms were the same in both organs. 
As an additional proof he found in a case of salpin- 
gitis in one tube a localized cystitis on the same side of 
the bladder. An infection may come from rupture 
into the bladder of purulent collections in other ab- 
dominal vnscera, as for instance, tubal, ovarian or 
perityphlitic abscesses. 

The direct predisposing cause of cystitis has not 
yet been fully determined. We know that pyogenic 
organisms may be present in a normal bladder and 
never set up c)'stitis. This has been proved by ex- 
periments both on the lower animals and on human 
beings. The typhoid bacillus and many other pyo- 
genic organisms are excreted by the kidneys and 
pass through the bladder without doing it the slight- 
est harm. This shows that the presence of bacteria 
alone is not sufficient in the normal bladder to set 
up an inflammatory reaction. It is well known that 
after a slight traumatism of the bladder wall cystitis 
nearly always results. Under this head we can place 
cystitis following catheterization and instrumenta- 
tion of the bladder, also the cystitis produced by 
stone in the bladder. We also find cj'Stitis accom- 
panying the growth of either benign or malignant 
neoplasms of the bladder .vail. The ingestion of 
irritating drugs, by their caustic effects on the vesi- 
cal mucosa, prepare a suitable soil for the entrance 
of the bacteria. 

A question at present receiving much important 
consideration is whether the gonococcus of Neisser 
is or is not capable of producing cystitis. The 
French observers believe that this germ cannot pro- 
duce a true cystilis, yet a few cases have been re- 
ported which point to a pure infection by this or- 
ganism. Krogus and Barlow ' each record cases, as 
does Melchior, and more recentl)- Wertheim' 
demonstrated before the Berlin Obstetrical and 
Gynecological Society a preparation from a case of 
gonorrheal cystitis which showed the capillary and 
precapillary veins filled with gonococci and a con- 
dition of gonorrheal thrombosis and thrombophle- 
bitis. The cystitis was secondary to a gonorrheal 
vulvovaginitis and was associated with infection of 
both ulnar joints. The microscopic sections were 
made from a portion of the mucous membrane ex- 
cised during cystoscopic examination. A small por- 
tion of the excised mucous membrane was placed in 
prepared blood-serum with the result that a pure 
culture of gonococci was obtained. Wertheim says, 
regardless of the statement of Guyon, Bumm, 
Sanger, and others (that a gonorrheal infection of 
the bladder is always a mi.xed infection), that the 
finding of gonococci alone in this case proves beyond 

^Arck.f. Dermat. u. Syph., 1S92. 

- Zeitschr. f. Geburlshul/t u. Gynakotogie., Band 35, Heft i, 
1S98. 



74 



CYSTITIS; ITS CAUSE AND TREATMENT. 



[Medical News 



doubt that pure gonorrheal cystitis can occur. A 
gonorrheal thrombosis and thrombophlebitis had 
never before been demonstrated, and the writer be- 
lieves that a step toward a better knowledge of this 
disease has been made. He says it is useless to seek 
for the gonococci except in the very acute stage as 
they very soon disappear. On the other hand, 
Bauzet, in a very interesting paper on this subject, 
makes the following statement: "The gonococcusof 
Neisser is not proved to have pyogenic properties, 
except as regards the mucosa of the urethra, the con- 
junctiva, and the female genital organs." I have 
seen a number of cases in which cystitis was present 
or followed directly after a posterior urethral gonor- 
rhea, but I have never been able to find the gono- 
coccus of Neisser alone; it was always accompanied 
by other pyogenic organisms. 

The pathogenic bacteria which have been most 
commonly found in cystitis are the following: ba- 
cillus coli communis, streptococcus pyogenes, staphy- 
lococcus pyogenes albus, citreus, and aureus; bacil- 
lus lactis aerogenes, tubercle bacillus, gonococcus of 
Neisser (mixed infection), the typhoid bacillus, and 
several varieties of the proteus. We may state that 
from our present knowledge the following facts may 
be laid down as the cause of cystitis: 

1. Cystitis is always caused by the presence of 
bacteria. 

2. The mere presence of bacteria is insufficient to 
cause cystitis; a further predisposing cause is nec- 
essary. 

3. Under favorable conditions any pathogenic or- 
ganism may give rise to cystitis. 

4. The entrance of pathogenic organisms into the 
bladder may be through the urethra, through the 
ureter from an infected kidney, from inflammatory 
areas in the neighboring parts, and through the 
blood-stream and the lymphatics. 

From what has been said in regard to the cause of 
cystitis it is plain that the prevention of this disease 
depends upon the avoidance of local congestion and 
of the entrance of the germs into the bladder. Local 
congestion may occur in spite of our best efforts to 
prevent it, and septic germs may enter the bladder 
from causes over which we have not the slightest 
control. It is seldom that we are called to see a 
case of cystitis in which these features are not already 
present. 

Proper hygienic and antiseptic precautions are nec- 
essary in all cases of surgical interference in the 
urethra and bladder and all instrumentation in or 
about the urethra or bladder must be conducted 
under strict antiseptic precautions. The entire gen- 
ito-urinary tract should be made as near aseptic as 
possible and this can be accomplished through the 



administration of certain drugs which have the power 
of preventing the formation of bacteria in the blad- 
der. Acute cystitis is best treated by rest in bed. 
Free catharsis should be established in every instance, 
and the patient should have one or more watery move- 
ments of the bowels during each twenty-four hours. 
This is best accomplished by the administration of 
sulphate of magnesia every second or third day. If 
pain (tenesmus) is severe a narcotic is indicated. 
Morphin is especially useful if there is loss of sleep. 
A method that I have used with good results when 
pain on urination is severe is to instill a few drops of 
a four-per-cent. solution of cocain, and after a few 
minutes from ten to fifteen drops of a six-per-cent. 
nitrate of silver solution. Another procedure from 
which I have seen good results is the use of rectal ir- 
rigation of hot water for ten to fifteen minutes, fol- 
lowed by a hot enema of 25 to 30 drops of tincture 
of opium in four to six ounces of warm starch water. 
Suppositories of opium are useful in allaying pain. 
One that I am very fond of, and from which I have 
had good results, is the following: 



Ext. hyocyami 
Camphora; monobrom. 
Morphin sulphat. 
Cocoa butter 



. gr. 1 

. gr. ii 

. gr. ss 

. q. s. 

The diet should be bland; during the acute 
stage nothing but milk and Vichy, 4 ounces of 
each being administered every two hours. Of drugs 
there is a long list to choose from. I have used 
many of them and none has given me such good re- 
sults as has been derived from the use of urotropin in 
5 grain capsules, four times daily. 

We are advised never to wash out the bladder 
during an acute attack of cystitis. This is good ad- 
vice, as long as the urine remains bland and the 
bladder is emptied at each act of urination. But 
the urine should be watched and as soon as it pre- 
sents any evidence of undergoing decomposition irri- 
gation should be begun at once. For this purpose a 
warm twoper-cent. solution (100° to 105° F.) of 
boric acid or ichthyol may be used to good ad- 
vantage. One of the best formulae for irrigation is 
that introduced by Lobingier,' viz.: 

Acidi borici . . . . . 3 i 

Borax ...... gr. xxx 

Sodium chlorid gr. xv 

Aqus ...... Oil. 

Warm to 100° or 105^ F. The irrigation can be 
performed through a double-current catheter or a 
meatus nozzle, after the method suggested by Janet 
of Paris. The latter method is by far the best and 
is aseptic. 

In the treatment of chronic cystitis active inter- 

» Medical News, October 15, 1892, p. 425. 



July 15, 1899] 



CYSTITIS; ITS CAUSE AND TREATMENT. 



ference is always necessary, and even then a per- 
manent cure cannot be assured. To-day the dis- 
ease is generally treated under four different heads, 
viz.: first, by medicines; second, by irrigations; 
third, by direct topical treatment, and fourth, by 
surgical interference. The treatment of chronic 
cystitis by drugs with an idea of producing a cure is 
fallacious. That certain drugs do exert a beneficial 
influence over some of the symptoms cannot be 
denied, and it is wise to administer a drug that an- 
swers the requirements the best in each individual 
case. Many different drugs are advised; some act 
well in some cases, while in others no appreciable 
diminution of the symptoms have been observed. 
In 1895 Nicolaier' called the attention of the pro- 
fession tourotropin as a drug to be used in the treat- 
ment of urinary affections, and especially its prop- 
erty of preventing fermentation of the urine and the 
development of bacteria. In my opinion it is the 
best and safest drug that we have at our command. 
I have been using it during the past three years, and 
I have yet to find a case in which any disagreeable 
after effects were observed. As a urinary antiseptic 
it is superior to any other drug that I know of. 
The dose is from 3 to 7 grains four times a day. 
Urotropin has no direct effect on any existing lesion 
or inflammation; it simply renders the urine aseptic, 
and is thus a valuable aid in conjunction with other 
local treatment, except in cases of plain bacteriuria 
and ammoniacal decomposition without any inflam- 
mation of the mucous membrane of the bladder. 
In such cases it is a specific. 

Irrigation of the bladder in chronic cystitis is 
recognized as one of the best methods of treatment 
at our command. The only method that should be 
followed is that of irrigation through the meatus by 
the meatus-nozzle, as suggested by Janet of Paris. 
The strictest aseptic precautions must be ob- 
served, such as cleansing the glans penis, the meatus, 
the urethra, and especially the instrument used, as 
well as the hands. Irrigation may be practised by 
allowing a small quantity of the irrigating fluid to 
run into the bladder and then have the patient void 
it, or better, allow a sufficient amount to run in un- 
til the bladder is moderately distended or un- 
til the sensation of a full bladder is conveyed to the 
patient. This latter procedure is the best as 
the entire mucous surface of the bladder is thus 
thoroughly cleansed. 

When there is much pus and mucus present in the 
urine it will be well to use a one-sixteenth-per-cent. 
solution of salicylic acid as recommended by ?]ryson.' 
With the same end in view a i-per-cent. solution 

' Deutsche Med. Woch., No. 34, 1895. 

^Jour. Cut. and Geri.-Urin. Dis.^ February, 1892. 



of nitrate of silver, bichlorid of mercury, i to 50,- 

000 or I to 60,000, or a i^-per-cent. solution of 
carbolic acid may be used, but none of these is so 
pronounced or lasting as the solution of salicylic 
acid. 

In commencing with this form of treatment it is 
best to give two treatments a day, one in the morn- 
ing, the other in the evening. At the morning se- 
ance it is best to employ one of the stronger solu- 
tions, and a milder solution, such as the one 
suggested by Lobinger or Thompson, at the evening 
treatment. After the most distressing symptoms 
have disappeared, if the urine remains alkaline, with 
a tendency to throw down phosphates, Harrison' 
recommends the use of 5 grains of citric acid to 
the pint of warm water. When the urine remains 
purulent Nunn* advises the use of quinin, i grain to 
the ounce of water, to which should be added i 
drop of nitric acid. In these cases I have used a 

1 -per-cent. solution of ichthyol with a good deal of 
benefit. 

At the first blush it may appear that this method 
of treatment is fraught with danger to the ureters 
and kidneys. In my experience I have never ob- 
served any symptom that would point to this compli- 
cation, and I believe that it is next to impossible to 
force fluid into the ureters or kidneys by irrigating 
the bladder from the meatus. I have experimented 
in the way suggested by Lewin and Goldschmidt,' 
and by Guyon and Courtade, ' and never once have I 
been able to force the fluid into the ureters or kid- 
neys from the meatus through the bladder. 

The practice of instilling medicine into the blad- 
der in the treatment of cystitis was introduced by 
Guyon of Paris who is a great advocate of this 
method of treatment. The solutions that are most 
used are nitrate of silver in the strength of from i 
to 15 per cent., and corrosive sublimate in the 
strength of i to 10,000 to i to 2000, from 15 to 60 
drops being instilled at one sitting. The amount 
introduced is allowed to remain in the bladder from 
15 to 30 minutes, when it is washed out with a mild 
antiseptic fluid. I have found that iodoform in ster- 
ilized oil is very efficient in the strength of 5 to 10 
per cent. This method is especially recommended 
by Guyon for the treatment of tuberculosis of the 
bladder. 



Surgeons for San Francisco On July 5th the War 

Department ordered eleven additional surgeons to report 
to General Shatter for duty in the new general hospital 
at the model camp in San Francisco. 

' "Twentieth Century Practice," Vol. I., p. 239. 
' Lancet, February 23, 1898, p. 356. 
s Fi'rc/io-.i's Arc/iiv, 1893, p. 33; 1898, p. 104. 
• An. des. Org. Gen.-Urin.. March, 1897, p. 225. 



76 



A CASE OF PLACENTA PREVIA. 



[Medical News 



CLINICAL MEMORANDUM. 



A CASE OF PLACENTA PREVIA.' 

By CHARLES A. HELVIE, M.D., 

OF CRETE, NEB. 

C. Q., aged twenty-two years, English, housewife, 
married, entered the maternity of the Erie County Hos- 
pital, Buffalo, N. Y., July 20, 1895, at 4.30 p.m. 

Personal History. — She had never had any sickness. 
Menstruation always regular, four-weekly type. She was 
slight in figure and appeared anemic. 

Family history. — Mother died of "brain fever." 

Physical Exatnination on Admission. — Inspection : no 
abnormalities. Palpation: Foot presentation with head 
to left. Position transverse with dorsum in fundus. 

Auscultation. — Fetal heart heard above umbilicus; fre- 
quency 160; regular. 

Vaginal Examination. — Vagina roomy. Cervi.x ef- 
faced. No dilatation. 

Mensuration. — Height above pubes of navel 13 cm., 
of fundus uteri 19 cm. Distance from ensiform to fun- 
dus 4 cm. Distance between spines, 22 cm. Between 
crests 26 cm. Conjugates, extremes 19 cm. 

Urine. — No specimen obtained before labor began. 

Labor. — Pains began at 7.30 p.m., three hours after 
admission. 

Ftrst Examination after Beginning of Labor. — 8.45 
P.M. Dilatation complete. Bag of water intact and near 
vaginal orifice. Pains fair. 

Second Examination. — 10.00 P.M. Foot found pre- 
senting to anterior and nearly a finger's length from vag- 
inal orifice. Pains same as before. 

Third l-lxamination. — 11.15 P- '^■- Bag of water still 
intact but near vaginal orifice. Presenting foot half a 
finger's length in. Pains almost ceased for a time. 

Fourth Examination. — 12.30 A.M. Membranes in- 
tact. Fetal heart sounds not heard. No fetal move- 
ment detected. 

There had been some hemorrhage all along, so that the 
napkins had to be changed frequently. After the third 
e.xamination (11. 15 P.M.) the hemorrhage increased 
markedly. During the examinations the patient always 
complained of pain, so that they could not be made as 
thorough as they should have been. At i.oo .\.m. it 
was decided to anesthetize the patient in order to make a 
more complete examination. Chloroform was used. 
The case was now found to be one of placenta previa. 
The placenta was high enough up to be beyond the reach 
of the examining fingers, until after the anesthetic was 
given. The edge of the placenta was then felt 
to the right, anteriorly. The membranes were rup- 
tured artificially and rapid delivery begun. When the 
membranes were ruptured the cord was found to be pro- 
lapsed. Delivery was effected by traction on the feet 
and legs. 

Birth at 1.30 A. M. Child was still-born, but vigorous 

efforts were made to resuscitate it. These were partially 

successful. The child died two hours after birth. It was 

well formed. Its weight was 3 lb. 11 oz. While I was 

' Read before the Nebraska State Medical Society. 



working with the child, my colleague, Dr. Robinson, took 

charge of the mother. 

Placenta expressed (Crede) at 1.32 a.m. Ergot, gtt. 
XXV, by hypodermic injection was then administered to 
the patient. The weight of the placenta was io|< oz. 
It was of an oval shape, thin and soft. One edge was 
very dark colored and contained a blood- clot which occu- 
pied about one-fourth of the placenta. The surface was 
studded with white infarcts. 

The cord was 65 cm. in length. Its insertion was 
marginal. It was small near the placental end and grad- 
ually enlarged toward the fetal end. Near the fetal ex- 
tremity it was distorted by large venous dilatations and 
near the middle there was quite a large nodule of Whar- 
ton's jelly. 

Immediately after delivery the patient went into col- 
lapse. Her head was quickly lowered, hot water-bottles 
were placed about her and vigorous massage of the ex- 
tremities and uterus was kept up. Hypodermic injections 
of brandy were given about every fifteen minutes until 
five doses had been given. Strychnin sulphate, -J^ of a 
grain was also given hypodermically once every hour 
until three doses had been given. Inhalations of amyl 
nitrite were given at first, and later oxygen was adminis- 
tered until four gallons had been used. Several high en- 
emas of hot salt solution were given and one enema ot 
hot strong coffee. It was three hours from the time the 
collapse set in before the patient began to rally. At the 
end of this time the uterus began to show signs of con- 
tracting under the massage, and the patient complained 
of pain and nausea. A vaginal douche of hot mercuric 
bichlorid, I to 5000, was then given and the binder put on. 

Her temperature at 8.45 p.m. was 99°, at 12.45 a.m., 
98' and three and half hours after delivery 97.5° F. 
The pulse at this time was 1 20. 

{^ bout eight hours after delivery the patient became 
restless, complained of pain in the abdomen and began 
to vomit. The vomiting continued for about thirty-six 
hours. Nothing seemed to relieve it. During this time 
hot milk I viii was given per rectum, every six hours. 
The pain in the abdomen was relieved only by permitting 
the patient to lie upon her right side. 

During the first twenty-four hours a small amount of 
urine was passed but urination was always accompanied 
by a bowel movement. Thus what urine was passed was 
so mi.xedwith fecal matter that it could not be examined. 
At the end of the first twenty-four hours the patient was 
catheterized but no urine obtained. It was not until the 
fourth day that a specimen for examination could be ob- 
tained. This was bv catheter and amounted only to 3 iii. 
It was acid in reaction. The specific gravity was not 
obtained. The heat and nitric-acid test showed it to be 
almost solid with albumin. Urea, by the Doremus test, 
was .03. By the microscope there was shown epithelium, 
pus, bacteria, and urates. No casts were found. 

The patient's condition became gradually worse and 
death ensued on the fifth day. During the last twenty- 
four hours she became comatose. Her breathing be- 
came stertorous and of the Cheyne-Stokes type. The 
skin became dry and harsh and minute crystals of urea 



Jllv is, 1899] 



MEDICAL PROCESS. 



77 



could be seen glistening upon it. With this condition 
there was present a verj' peculiar odor. 

The cause of death was uremia consequent upon neph- 
ritis with almost complete suppression of urine. Whether 
this nephritis was ante partum or acute post-partum it is 
not possible to say positively smce no autopsy was made 
and there was no examination of the urine before labor 
set in. The previous anemic condition of the patient, 
together with the hemorrhage during labor, were factors 
which contributed largely to the disastrous result. 
The chloroform anesthesia may have been another factor 
of considerable importance. 

I have said nothing of the treatment pursued in the 
case after the first signs of uremia. In passing I will 
Slate that the usual recognized methods of treatment were 
followed : hot baths and hot packs, hypodermic medica- 
tion to sustain the strength and induce perspiration, and 
finally intravenous injections of normal salt solution. 

What would have been the result in this case if the 
labor had been conducted differently? The question 
hinges upon a point in obstetrical teaching — spontaneous 
rupture of the membranes or their artificial rupture, early 
or late. For the most part I received my obstetrical 
training under the "immortal" Jaggard. One of his dogmas 
was that the bag of membranes, being a natural dilator 
not only of the os uteri but of the whole parturient canal, 
should be left alone and allowed to rupture spontaneously, 
unless there were some very positive indications for inter- 
ference. Just here it may be urged that those indications 
were present in the continued hemorrhage. In reply to 
this it can be said that the hemorrhage, although continu- 
ous, was only slight, not so much as often accompanies 
the slight lacerations of the cervix in process of dilatation. 
There was no history of hemorrhages before labor. On 
account of the hypersensitive condition of the parturient 
canal and the apparent high position of the placenta the 
true state of affairs could not be determined until after 
complete anesthesia. It was not until then that the case 
was determined to be one of placenta previa. 

One of my colleagues in the hospital. Dr. Mord, in ac- 
cordance with the training that he had received, prac- 
tised the rupture of the membranes as soon as the cervix 
was completely dilated. In this case, it has seemed to 
me, that if I had ruptured the membranes at 8.45 p.m., 
at the time when dilatation was found to be complete and 
only one hour after the beginning of labor, the final re- 
sult would have been quite different ; both mother and 
child might have been saved. The child probably would 
not have been asphyxiated. There would have been 
saved to the mother at least four hours when her strength 
was slowly ebbing away, while the subsequent uremia 
might have been averted. 

I report this case not alone because of the extreme interest 
that it has had for me, but that it |may serve to warn 
others to be on their guard for even the slightest danger 
signal. 

I am well aware of the fact that the conduct of the 
case may be severely criticised. It was partially with 
the purpose of eliciting this criticism that I have pre- 
sented it somewhat in detail. 



MEDICAL PROGRESS. 



Maternal Impressions. — OGLE {Charlotte Med. Jour., 
May, 1S99) and Land.au (Monats.f. Geburts. u. Gyndk., 
May, 1899) discu.ss the philosophy of this puzzling sub- 
ject. Both cite numerous well-authenticated instances in 
which the birthmark or deformity of the child suggests 
more or less some fright or accident which occurred 
to the mother during her pregnancy. Both admit 
that it is difficult to explain the very widespread belief in 
maternal impressions which has existed from the earliest 
times in ever)' country. Ogle says that it is hard to im- 
agine how a mental impression of the mother can alTect the 
development of a portion of the child, in the absence of any 
direct nerve connection between the two, but he apparently 
hesitates to set down as pure superstition or error of ob- 
servation all the recorded cases of maternal impressions 
from Aristotle to the present time. Landau is more out- 
spoken, for in the closing words of his article, he says, 
"I admit that it is striking that earnest thinkers of great 
power of observation, wide learning, and sharp intellect, 
bring forward certain cases which seem to uphold the 
primitive belief. Still, great men have made mistakes be- 
fore now. Maternal impression is and remains a super- 
stition, and despite Welsenburg's highly instructive work 
on the subject it has not become worthy of scientific rec- 
ognition." 

Radical Cure of 'Slipped" Hernias of the Large Intes- 
tine. — FroeliCH {Gaz. Heb. de Med. et dc Chir., April 
25, 1899) discusses the radical cure of those hernia of the 
large intestine, either cecal or sigmoidal, which have 
"slipped" down behind the peritoneum, and are there- 
fore partially or wholly without a peritoneal sac. This 
condition has been most perplexing to surgeons, and 
most operations on strangulated hernise of this type 
have been followed by the death of the patient, while the 
operations done for radical cure when no strangulation 
existed, have been unsuccessful in curing the hernia. 
The author reports three such cases, in two of which at- 
tempts to separate the intestine together with the sac, 
from the tissues about the ring, in order to reduce the 
hernia en masse, were followed by fecal fistute. All 
three patients recovered, but without cure of the hernia. 
From a study of these and twenty-one published cases, 
Froelich concludes that in irreducible inguinal hernia one 
ought always to keep these "slipped" hernia in mind. 
The diagnostic points are the presence of fecal lumps, 
distention when gas is pumped into the rectum, a draw- 
ing feeling at stool, and often a diminution in the size of 
the hernia after evacuation of the bowels, and an irre- 
ducible hernia from the beginning. In regard to the 
treatment, it is advised to dissect sac and intestine pos- 
teriorly with the fingers high enough up to permit of the 
easy closure of the ring. Failing in this, the intestine 
should be resected. Even then one must not expect to 
obtain a radical cure, but the condition ought to be such 
that the hernia can be held in place by a truss. In 
strangulated hernias of this type, the surgeon should re- 
member that there may be loops of small intestine which 



78 



THERAPEUTIC NOTES. 



[Medical News 



are also strangulated, and which must be freed and re- 
duced if recovery is to be secured. 

Error of Sex as a Ground for Divorce. — Neugebauer 
(Ceniralbl. f. Gyndk., May 6, 1899) has collected re- 
ports of no less than fifty cases in which divorce has been 
granted on account of an error in the sex of one of the 
contracting parties. It seems incredible that such a mis- 
take should occur so often, but the conformation of the 
genitals of some of these hermaphrodites was such as to 
deceive medical men who could not in some instances 
agree upon the sex of the individual, even after an exam- 
ination. One remarkable case is recorded in which a 
male hermaphrodite had successively three husbands, and 
it was only after she, or rather he, had given a venereal 
disease to the third husband that the latter applied for a 
divorce. In forty-six out of the fifty recorded cases a 
man had married a male hermaphrodite. In one case 
the sex of the parties is not given, and in three instances 
women married female hermaphrodites. In one of these 
instances the supposed husband later became pregnant, 
and was dehvered of a full-term child. There are numer- 
ous instances in which a matrimonial engagement has been 
broken on account of the discovery that the parties to the 
agreement were of the same sex. 

Repeated Ccesarian Section. — Pollak {Ceniralbl. f. 
Gyndk., April 15, 1899) looked up the literature of Caesa- 
rian section and found that it had been performed a second 
time upon the same patient no less than thirty times. A 
still more remarkable fact is that in twelve cases it has been 
performed three times upon the same patient, the operation 
being twice concluded by the removal of the uterus. 
Four women have had Cassarian section performed upon 
them four successive times, while one, a patient of Birn- 
baum, was five times subjected to this operation, this 
unique series of deliveries being terminated unfortunately 
by the death of the mother from pulmonary embolism. 
Pollak adds the details of a case in which Cassarian sec- 
tion was three times performed. The last operation was 
done by himself, and a careful examination of the uterus 
showed that its wall at the sites of the previous incisions 
was as solid and as thick as at other places. 

In this connection may be mentioned a case reported 
by Prj'or in which Cassarian section was successfully per- 
formed upon a woman whose abdomen had been opened 
five years previously for the removal of a large fibroid. 
At the time the uterus was opened, another fibroid was 
present, but it was decided not to remove the tumor. It 
grew so rapidly, however, that laparotomy had to be per- 
formed within three months, at which time the whole 
uterus was successfully removed. 



THERAPEUTIC NOTES. 



Treatment of Acute Rheumatism Prophylactic of Pericardi- 
tis — Delearde (La Presse Med., April 29, 1899) says 
that no other drug is so good as salicylate of soda to pre- 
vent pericarditic sequela after acute articular rheumatism. 
Three rules are to be observed, viz., to give large initial 



doses of the salicylate, to give it at short intervals on ac- 
count of its rapid elimination, and to keep up its adminis- 
tration for at least ten days after the disappearance of all 
pain. To adults he gives from 90 to 1 20 grains a day 
in the beginning of the attack, in divided doses, every 
three or four hours. After the disappearance of acute 
symptoms the dose is reduced so that the patient gets 
only 45 to 60 grains a day. The medicine is given either 
in capsules or in such a mixture as the following : 
B Sodii salicylatis . . . . 3 jss 

Spiritus vini rectificati ... 3 ijss 

Syr. ribis . . . . . 3 x 

Aquse destillatae . . . q.s,ad|iij. 

M. Sig. Take the whole in doses of a tablespoonful 
during the twenty-four hours. 

Treatment of Impetigo Contagiosa. — The crusts are to be 
removed by repeated washings with warm water and 
soap (Stelwagox, "Keating's Cyclopedia," vol. v.) 
and an ointment of ammoniated mercury of the strength 
of from 10 to 20 grains to the ounce. In cases in which 
the itching is severe a lotion composed of a saturated so- 
lution of boric acid, containing '2 a dram of carbolic 
acid or resorcin to the pint, should be applied. This 
prevents innoculation of new points. 

Treatment of Acute Dysentery. — SODRE ("Twentieth Cen- 
tur)'," vol. xvi) recommends in lieu of the large doses of 
infusion of ipecac often given the following : 

B Pulv. ipecac. . . . . . gr. iss 

Pulv. opii ..... gr. '5 

Calomel ..... gr. V • 

To be given in a capsule every two hours, or adminis- 
ter about fifteen minutes before the first dose of ipecac, 
12 drops of a mixture containing menthol (gr. iii), tinct. 
opii (gr. iss), and Jamaica rum ( 3 v), and apply a mus- 
tard plaster to the epigastrium. If the ipecac is not toler- 
ated saline cathartics should be given in small doses, often 
in alternation with the ipecac. The salines — sulphates of 
sodium or magnesium in doses of about 2 drams — are indi- 
cated when there is constipation, or small evacuations with 
much colic and tenesmus. Astringents — opium, bismuth, 
and salol — are useful, but must be given cautiously and 
alternated with the saline cathartics. Ulceration in the 
rectum and colon is to be treated by enemata, containing 
opium and bismuth. The following plan of treatment is 
very often satisfactory : Sulphate of soda (or magnesia) is 
given on the first day of the disease, and on the second, 
third, and fourth days, every three hours, a capsule con- 
taining: 

Magnesia . . . . . gr. iv 

Bismuth subnitrate . . . gr. vi 

Pulv. ipecac . . . . gr. i 

Pulv. opii . . . . . gc-'A- 

For Acute Diarrhea. — 

5 Sodii bicarbonatis . . . . 3 i 

Spts. ammonii arom. . . . 3 iii 

Tinct. cardamom! comp. . . . 3 vi 

Aq. cinnamomi . . q. s. ad. 3 \'i. 

M. Sig. Two tablespoonfuls every two or three 
hours. — Veo. 



July 15, 1899J 



SUMMER DIARRHEA IN INFANTS. 



79 



The Medical News. 

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SATURDAY, JULY 15, 1899. 

THE TREATMENT OF SUMMER DIARRHEA 
IN INFANTS. 

We are glad to be able to present to our readers, 
just at the time when its very practical points may 
be of most service to them, Dr. Chapin's paper on 
this timely subject, with a detailed report of the 
discussion that followed it at the New York Academy 
of Medicine at its last meeting of the season. There 
is nothing that is absolutely new to be said on the 
subject, but the emphasis laid on certain points in 
the course of the discussion shows that physicians 
who have a very large experience in children's dis- 
eases are now definitely agreed as to the advisability 
of certain measures that have been more or less in 
doubt though every year growing more and more 
into the practice of the profession. 

The theory that children should not be given 
carbohydrates because they secrete no diastasic fer- 
ment to digest them is now definitely abandoned 
and two distinct advantages are claimed for the 
mixture of carbohydrates with baby's milk. First, 
there is the mechanical separation of the particles 
of the coagulated milk which prevents its coagula- 



tion in thick solid masses incapable of pene- 
tration and digestion by the stomach juices; and 
second, certain antiputrefactive action is claimed 
for carbohydrates. Their fermentation which used to 
be so much dreaded or at least railed about, it is 
now urged, causes the liberation of free acids and 
these prevent the growth of intestinal bacteria which 
especially luxuriate in an alkaline medium. When 
cow's milk is used, then, in the feeding of infants in 
the summer time especially, its dilution with barley- 
water or some other cereal solution is considered 
much more to be preferred to its dilution with plain 
water. 

As to treatment all the specialists in children's 
diseases insist on the stoppage of all feeding just as 
soon as diarrhea asserts itself in the hot weather. 
There is great danger in delaying the institution of 
this radical measure while an over-anxiety that 
would stop the administration of milk, and 
so perhaps anticipate the necessity for absolute 
gastro-intestinal rest by a few hours, can do very 
little if any harm. A single attack of vomiting in 
a child whose stools are more frequent and watery 
than normal must be the signal for the withdrawal 
of all milk from the dietary if the physician would 
not neglect his plain duty as outlined by the best 
recent experience. 

As to drugs, not much can be said. All authori- 
ties are agreed that opinm must not be used, in the 
hope to control by its help the number of stools. 
It must never form part of the diarrhea mixture itself 
of which the main ingredient should be one of the 
salts of bismuth; it must not be administered tmtil 
after stomach and intestines have been relieved by 
purgation, lavage, and high injections of any toxic 
material that is present. It must be employed only 
when there are direct indications for it, /. e., only 
when there is exhausting restlessness or tenesmus and 
pain. For the restlessness it has been pointed out 
that hydrotherapy forms an excellent substitute for 
opium and one that carries with it none of the dan- 
gers of the rather treacherous drug. Whenever the 
temperature of the little patient is above 102.5° F- 
for any length of time it should be ])laced in a bath 
somewhat above 90°, which should be rapidly low- 
ered to about 80°, not lower. As a rule not more 
than a very few minutes will be necessary, but the 
bath may be continued for ten minutes, a cold cloth 



8o 



RECENT EPIDEMICS OF CEREBROSPINAL MENINGITIS. 



[Medical News 



being kept on the child's head. For tenesmus the 
local use of opium per rectum is most advisable, 2 or 3 
drops of the tincture in a tablespoonful of starch water 
relieving the pain, decreasing the fruitless efforts at 
stool, and avoiding most of the deleterious eflects 
of the drug on the general system. 

Abroad, of very late years a good deal has been 
said of the value of tannigen in controlling the 
stools. Dr. Blackader of Montreal, in the March 
number of ' 'Progressive Medic ine" in an excellent re- 
view of the recent literature on summer diarrheas, 
quotes no less an authority than Escherich, the well- 
known Professor of Children's Diseases at the Uni- 
versity of Graz in Austria, who speaks very favor- 
ably of tannigen and claims for it a distinct 
disinfectant and bactericidal effect. Kraus and 
Biedert have also written in its praise, especially for 
chronic intestinal catarrh. It is a tasteless powder, 
therefore easily administered and is given in doses 
of 2 to 5 grains four times a day. It is espe- 
cially useful in cases of follicular enteritis, where local 
measures are of little avail. Its administration is 
continued in lessened doses after the acute symptoms 
have subsided and it is said to hasten convalescence, 
which is often apt to be tedious. 

Stimulants used early in the case, though sparingly 
until marked signs of prostration assert themselves, 
are growing in favor. Recent reliable physiological 
observations, notably Atwater's work, seem to con- 
firm an old view with regard to alcohol, that it is 
o.Kidized in the body and does replace food material 
to a very appreciable extent. When all milk feed- 
ing is stopped it undoubtedly serves to keep up the 
child's strength. Bouillon has been recommended 
for the same purpose. Meat-products generally, 
while acting as effective nutrients do not seem to 
furnish the favorable culture-medium for micro-or- 
ganisms that milk does. 

For the severe states of depression that develop 
in the serious cases of diarrhea the subcutaneous in- 
jection of normal salt solution has sometimes given 
excellent results. Very often these cases are hope- 
less. The paralysis of cellular activity has been too 
great to permit reaction. The normal salt solution 
seems, however, in many cases to dilute the toxins 
in the circulation and arouse conservative processes 
that make for resistive vitality. In an infant an 
ounce of the solution may be injected into the thigh 



or back by means of a hypodermic needle or an or- 
dinary Davidson syringe and will often be followed 
by a most favorable reaction. The injections may 
be repeated about three times a day. Even in what 
seems hopeless collapse the effect is often according 
to French writers almost marvelous. 

RECENT EPIDEMICS OF CEREBROSPINAL 
MEN I NG I TIS. 

There is still much to be learned about epidemic 
cerebrospinal meningitis, and Europe looks to 
America for this information, as the disease is rarer 
in the Old World than in the new. Class, a member 
of the Health Department of Chicago, made a spe- 
cial study of the cases occurring in the recent epi- 
demic in that city, and gives in the J^ournal 0/ the 
American Medical Association, a summary of the 
histories of thirty-eight patients. The mortality of 
these patients was 65 per cent.; but he believes that 
a complete record of all the cases which occurred in 
the city during the epidemic would show a much 
lower mortality, since the thirty-eight reported by 
him were chiefly those of hospital practice. 

Since those in attendance upon the sick almost 
never take the disease, and since an epidemic does 
not spread by contiguity as does smallpox or yellow 
fever for instance, the contagiousness of the disease 
has been generally denied. There are, however, 
instances in which several members of one household 
are victims, a number of such being seen in the 
Chicago epidemic, and the majority of all the cases 
occurred in a territory of about one square mile. 
Class believes that the disease is contagious like 
phthisis, which would explain its spread geograph- 
ically in congested districts inhabited by persons of 
careless habits, and the lack of a similar spread 
among the intelligent and well-to-do. Several 
pathologists have show-n that the germ exists in the 
buccal and nasal mucus. As the germ is short- 
lived, it is easily understood why a family moving 
into rooms previously occupied by a patient, proba- 
bly would not contract the disease. An examina- 
tion of the dwellings inhabited by those who fell 
ill during this epidemic showed that many of them 
were in a very bad sanitary condition. The records 
of previous epidemics in other places are in accord 
with this statement. Hence, Class advocates the 
isolation of patients and the disinfection of their 



July 15, 1899J 



MEDICAL MATTERS IN NEW YORK. 



81 



evacuations, the correction of sanitary defects, and 
the notification of the sanitary authorities. Noth- 
ing new was brought out in the way of treatment. 
The writer mentions that difficulty in swallowing 
was observed in si.x cases each of which terminated 
fatally. 

Two other recent epidemics of this disease are 
reported. One was in the vicinity of Morgans- 
town, Kentucky, where fourteen patients, almost all 
of them males, died in from one to eleven days, 
(only two lived more than three days) while two 
were in critical condition at the time of report, 
and three or four others had recovered after a slight 
illness, the diagnosis of meningits in their case being 
doubtful. The other epidemic was in the vicinity 
of Henderson, Kentucky. Quinn, who reports the 
latter, estimated that one hundred persons were 
attacked, of whom about seventy-five died. In the 
midst of this epidemic, not a doctor or nurse suf- 
fered; but in adjoining counties where there were 
only a few cases, two doctors lost their lives from 
the disease. 

NEW INSTRUMENTS AND THE -DICHOTO- 
MOt/S •' M E T H OD I N MEDICtL ADVER- 
TISING. 

A DISTINGUISHED French surgeon, not long de- 
ceased, is said to have owed not a little of the very 
large and lucrative practice that he enjoyed to his 
uncompromising beliei in the practical application 
of the botanical principle of dichotomy, equal divi- 
sion, in the matter of consultation cases. His face- 
tious countrymen have taken the word which is 
applied by botanists to plants that multiply by divi- 
sion and applied it to medical men whose monetary 
accretions follow a similar law. They call them 
dichotomous, and have thereby enriched medical 
literature and language with a very expressive term. 

It is not unusual to have this system of "divvying 
up' ' referred to abroad as typically American. That 
it is not e.xclusively so the little legend we have 
just related and the very apt appropriate term 
the French have invented for what is evidently not 
an isolated incident, seem to show. A circular 
that has been going the rounds of doctors' offices 
here in New York, and very probably elsewhere in 
the country, indicates that there are other countries 
in Europe outside of France where the principle of 
division of the spoils is not unknown. At least it is 



scarcely to be supposed that the very promising sys- 
tem of division suggested in the circular sprang fully 
panoplied for the American campaign from the fer- 
tile brain of the American agents. 

The circular in question which smacks somewhat 
of its foreign origin in the construction of its 
phrases offers to physicians a goodly share of the 
spoils ($25 to S50) for every patient that on the 
physician's recommendation adopts the company's 
inventions for the removal of impotence. These in- 
ventions have the approval of high authorities 
abroad (names given), and cost S150 to S200. 
There have been grave doubts expressed abroad as 
to the advisability of the use of such methods, ex- 
cept in selected cases under extraordinary circum- 
stances, but with that we are not concerned. The 
method adopted for introducing the instruments de- 
serves the severest censure and should keep physi- 
cians, who value their reputations for honorable deal- 
ing with their patients, from advising them until such 
methods are abandoned. 

Manufacturers and agents must be taught the les- 
son that what is gained by these objectionable adver- 
tising methods with certain classes of the profession 
injure them so much with the great body of self-re- 
specting medical men that their use does not pay in 
the end. Only this practical commercial argument 
will reach such people. The methods in question 
are unfortunately becoming contagions in various 
trades connected with medicine, and this last ex- 
travagant manifestation should receive a severe re- 
buke. 

MEDICAL MATTERS IN NEW YORK. 

OPTICIAN'S AND PHYSICIANS — A ROBBER OF DOCTORS' 
OFFICES CAUGHT— ST. JOHN'S GUILD — FATAL 
ERROR IN DIAGNOSIS— THE HIGH-PRESSURE SYS- 
TEM IN NEW YORK SCHOOLS — TENEMENT-HOUSE 
REFORM — YELLOW FEVER IN NEW YORK HARBOR. 

The New York State Optical Society, at Us meet- 
ing at the Fifth Avenue Hotel on June 27ch, adopted 
a resolution deploring the action of certain med- 
ical societies of other States in endeavoring to disrupt the 
hitherto cordial relations which have e.xisted between 
physicians and opticians. 

In arresting one George Freeman the Brooklyn police 
seem to have caught an old offender, whose particular 
"lay" has been to call and ask for "the doctor" in his 
absence, be received in the waiting-room, and then to 
quickly disappear a few minutes after being left alone 
with whatever property he could conveniently carry ofif. 
On one occasion Freeman was seen bv the doctor's 



82 



ECHOES AND NEWS. 



[Medical New s 



servant to leave the house with a bundle. She ran after 
him, and accused him of theft. He then handed her 
two coats and an umbrella belonging to her employer, 
said he had made a mistake, and hurried away. 

The "Helen C. Juilliard," the new floating hospital of 
St. John's Guild, made its initial trip on July 6th. This 
boat has accommodation for 1 900 persons. Her most con- 
spicuous feature from a hygienic point of view is the bath- 
rooms, in which forty-one people can take salt-water spray 
baths simultaneously. Patients who are found to need 
longer treatment than can be given in a day's outing on the 
boat are carried to the Seaside Hospital of the Guild, at 
New Dorp, Staten Island. This establishment is gov- 
erned by a board of ten "New York and two resident phy- 
sicians. 

A few days since a man was stabbed in the abdomen 
during a quarrel. His assailant had used a pocket-knife. 
The wounded man went to a hospital near by, where his 
wound was examined. The surgeon considered it 
only a superficial wound, dressed it, and sent the man 
home. That night symptoms of peritonitis developed, 
and next day the wounded man was taken to Bellevue, 
where it was discovered that the abdomen had been pen- 
etrated. The man died. 

Dr. W. Gill Wylie, chairman of the Medical 
Board of the Board of Education, has begun an agi- 
tation for a reform of the present school system as it 
applies to girls. He considers that girls between the 
ages of eleven and sixteen are required to do too much 
work. A point gained thus far is that the age now fixed 
for admission to the Normal School is fifteen, instead of 
fourteen, as it used to be. Dr. Wylie says: "The dan- 
ger resulting from the amount of study required at pres- 
ent is not to the life of the girl, but, coming as it does in 
the formative period of a girl's life, the evil effects are 
bound to be manifest in her children." 

The tenement house committee of the Charity 
Organization Society has prepared a series of ordi- 
nances relating to tenement-house construction, and 
has presented them, in a report, to the Municipal Build- 
ing Commission. It was observed that New York City's 
tenements are a disgrace to the city and the State, that 
dangerous and unsanitary conditions are allowed to pre- 
vail in them, and that these conditions are growing 
steadily worse year by year. One of the suggested 
ordinances is aimed at the dark, narrow, and unven- 
tilated air-shaft, and the resulting dark, damp, and unven- 
tilated rooms that open upon it, and provides that the 
shafts shall not be less than six feet wide in any part and 
have not less than 150 square feet in superficial area. 
Other provisions are that no tenement shall be more than 
six stories high, that living rooms shall each have 600 
cubic feet of air space, that there shall be at least one 
bath-room for every twenty families in every tenement, 
and that the walls of tenements shall be carried three 
and one-half feet above the roof, so that the roof may be 
used as a playground. 

The Government Transport "McClellan" from San- 
tiago, Cuba, arrived at quarantine, July 6th, with two 
well-developed cases of yellow fever and two suspicious 



cases on board. The suspects did not develop the dis- 
ease, and have been discharged. One of the persons in 
whom the disease developed was Miss L. C. Clendenin, 
daughter of Surgeon-Major Clendenin, who died of yellow 
fever at Santiago the day following the departure of the 
"McClellan." The attack is mild in her case and she is 
being cared for at the quarantine hospital. The other case 
proved more serious and the patient submitted to treatment 
with the serum developed by Dr. Doty, Health Officer of 
the port. This serum is produced from the Sanarelli bacil- 
lus by injecting cultures directly into the veins of a horse. 
By this process Dr. Doty believes that a stronger anti- 
toxin is developed than by the subcutaneous method. 
He has despatched Dr. Bernard E. Baker of Charleston, 
South Carolina, with a supply of serum to Vera Cruz, 
Mexico, to give the remedy a prompt and thorough test. 
The epidemic of yellow fever which is raging there will 
enable him to use it in the early stage of the disease when 
it should be the most efficacious. To Mr. Lackey, the 
patient in the quarantine hospital, a subcutaneous injec- 
tion of the serum was given at eleven o'clock, two o'clock, 
and seven o'clock. During this time the patient's tem- 
perature fell two degrees and his general symptoms im- 
proved. 

ECHOES AND NEWS. 



Vienna Losing Its Lead as a Medical Center. — In the 
winter semester there were 1382 medical matriculants at 
Vienna, 1341 at Munich, and 1311 at Berlin. Wurz- 
burg stands next in the list with 713, while the once pop- 
ular Heidelberg had only 240. 

A Beer Tablet. — The latest reported German invention 
is a ' 'beer tablet. " The beverage is dried and compressed, 
and when water is added to the tablet, carbonic acid 
gas is formed, so that a foaming beaker is produced, as 
good, it is said, as if it were freshly drawn from the 
barrel. It is non-alcoholic of course. 

A Congress of Deaf-Mutes. — A committee of the lead- 
ing deaf-mutes of Paris is making arrangements for an 
international congress at the Exposition in 1900 and has 
asked the four following Americans to act as a sub-com- 
mittee : The Rev. A. W. Mann of the Central Western 
Deaf-Mute Mission of Gambler, Ohio, the Rev. J. M. 
Koehler, rector of All Soul's Church, Philadelphia, Pro- 
fessor T. F. Fox of the Fanwood Institution, Washington 
Heights, and E. A. Hodson, editor of T/ie Deaf-Mules' 
Jotirnal. 

Medicine's New Field. — Professor Charles Sedgwick 
Minot of the Harvard Medical School delivered the an- 
nual address to the Yale Medical seniors on June 27th. 
He said: "We are brought to the conclusion that though 
the primary functions of our medical schools is to educate 
practitioners of medicine, yet they ought to assume now 
the further and higher function of training medical inves- 
tigators. The requirements of comparative medicine 
call for more changes than we have yet mentioned. The 
very word comparative implies that animals shall be in- 
cluded in the study." 



July 15, 1899J 



ECHOES AND NEWS. 



83 



Koplik's Spots in Prague — Dr. Ludwig Knospel, the 
assistant of Professor Ganghofner in the dinic for child- 
ren's diseases at the German University of Prague, has 
followed carefully all the numerous cases of measles that 
came to the clinic and has found Koplik's spots of the 
greatest value for the early diagnosis of the disease. He 
reports that he has noticed the red spots with bluish-white 
punctations on the mucous membrane of the cheeks and 
lips from three to five days before the appearance of the 
usual eruptions of measles. {Schmidt's Jahrbucher for 
June, from the Prager Medicinische Wochenschrijt.) 

Decreased Death-Rate — The mortality bulletin of the 
New York State Board of Health for the month of May 
says that the number of deaths reported was ^9556, or 
just the average for the ten years past. It is 200 less 
than that of May, 1898, and 850 less than that of the pre- 
ceding month, the average daily mortality having been 
reduced from 346 to 308. For the preceding four months 
the average daily mortality was 370. The death-rate is 
reduced from 17.75 to 16.00. The decrease from last 
month is in acute respiratory diseases, from which there 
were 500 fewer deaths, and other local diseases caused 
300 fewer deaths. 

Report of Plague at Paris Denied. — The rumors that 
there have been deaths from the plague in Paris have 
been so persistently circulated that the matter was 
brought before the Academy of Medicine for investi- 
gation. The Academy has determined that the rumors 
were absolutely without foundation, other than an anony- 
mous letter written to an official of the goverment, stat- 
ing that five employees of the large department- 
store, Bon Marche, had died from plague contracted 
from handling rugs. The police at once took the matter 
up, and ascertained that there had been no deaths among 
the employees nor any cases of severe illness. The sani- 
tary conditions in the store were found to be as nearly 
perfect as possible. 

The Progress of tfie Plague. — Reports from Japan an- 
nounce that the plague still remains limiied to the island 
of Formosa. At Bombay, Calcutta, and other towns in 
the Bombay Presidency, the disease seems to be declin- 
mg. At Alexandria, Egypt, the total number of cases oc- 
curring previous to June 16th was thirty-two,, with ten 
deaths. Eight of these were of Europeans. A quaran- 
tine of si.x-days' detention has been declared at Naples on 
all ships having touched at Egyptian ports, and the im- 
portation of goods from all infected countries has been 
practically stopped. Turkey has established a ten-days' 
quarantine against vessels from Egyptian ports, Greece 
eleven-days' quarantine, and Malta two-day's quarantine. 
No further news has been received regarding the appear- 
ance of the plague at San Francisco. 

Epidemic of Diphtheria in the State Hospital for the Insane 
atWillard. — Diphtheria was reported July 5th as epidemic 
among the 2300 patients and 600 employees at the State 
Hospital for the Insane at Willard, near Geneva, N. V. 
The hospital has been placed under a rigid quarantine. 
There are now seventeen cases at the institution. It first 



appeared at the institution about a month ago, but the 
patients were quickly isolated. They recovered, and 
it was believed the disease had been stamped out. There 
was a further outbreak last week, and it is ttiis which 
has alarmed the authorities. The disease is of a very 
mild type, and attacks the younger persons. Of the 
seventeen now under treatment fourteen are em- 
ployees. The disease is being kept under control by the 
free use of antito.xin and no deaths have thus far been 
reported. 

The Study of Cancer at the Buffalo Laboratory. — The 
careful investigations into the etiology of cancer being 
carried on at the State expense at the Buffalo (New York) 
Laboratory are attracting attention abroad. It is reported 
that the British Cancer Society of London has appointed 
Dr. A. L. E. Duffy to investigate the work being done at 
Buffalo and collect data bearing upon the spread of the 
disease in the United States. As intimated by Dr. Ros- 
well Park in his article published in the Medical News 
April 1, 1899, the investigations at the Buffalo Laboratory 
point strongly toward confirmation of the germ theory 
of the disease. On the other hand Dr. Lambert Lack of 
London has recently reiterated positively his belief, 
founded on late investigation, in the old theory that can- 
cer is originally a local disease due to a specific injury to 
the basement membrane of mucous surfaces and allied 
structures. He also announces the discovery of a pro- 
phylactic and curative serum. 

Experiments in the Eradication of Malaria. Major 

Donald Ross, I. M.S., well known for his researches on 
the connection between the mosquito and malaria, will 
head a deputation of observers from the new tropical med- 
icine department of University College, Liverpool, which 
will go to Sierra Leone in August. They will be in 
Africa during the period of greatest prevalence of malaria 
and when the conditions are most favorable for observa- 
tions on the disease and especially as to the means by 
which it is spread. Major Ross considers that he will 
be able to demonstrate to the members of the expedition 
the truth of his theory that malaria is carried about by a 
certain species of mosquitoes and is directly caused by their 
bites. The special purpose of the expedition will be to 
determine what species of mosquitoes are malaria-bearers 
in a given region and then having found their haunts in 
swamps or ponds to cover them up and see if they will not 
be able to prevent in this way the further distribution of 
the disease. As this is the first practical attempt of this 
kind for the eradication of malaria, the outcome will be 
watched with great interest by the whole of the medical 
world. 

The British Medical Association. — The sixty-seventh 
annual meeting will be held at Portsmouth August, i, 2, 
3, and 4, 1899. The president-elect is Dr. John Ward 
Cousins. The following are the subjects announced for 
discussion in the several sections: "The Medical Tests 
Required at Present for Admission to the Public Services, " 
"The Prevention and Remedial Treatment of Tubercu- 
losis." Surgery: "The Diagnosis and Treatment of 



84 



OUR PHILADELPHIA LETTER. 



[Medical News 



Gunshot Wounds of the Abdomen," "The Prevention 
and Treatment of Syphilis in the Navy and Army.' Ob- 
stetrics and Gynecology : "The Treatment of Fever Fol- 
lowing Delivery, with Special Reference to Serum- 
therapy," "The Natural Menopause Compared with (a) 
the Menopause Produced by Removal of the Uterine Ap- 
pendages, and. (6) the Menopause Produced by Removal 
of the Uterus without Removal of the Appendages." 
Tropical Diseases: "Psilosis or Sprue; Its Relations 
(Etiological and Pathological) to Other Forms of Trop- 
ical Diarrhea, and Its Treatment," "On Thermic Fever 
(so-called Siriasis), with Special Reference to Its Alleged 
Microbic Causation." "The Agency of Insects in Spread- 
ing Infections." 

Yel/otv Fever in Cuba. — Since July 4th, the date of our 
last report, yellow fever has continued to claim its 
victims among the members of the various garrisons. 
At Santiago Surgeon-Major Ciendenin has died of the 
disease, also Chief Commissary-Major Heatwole and Sig- 
nal Officer McLaughlin. At Manzanillo iwo new cases 
were reported July 7th, and on the same date two deaths 
from the disease at Puerto Principe. At Santiago the 
troops have been placed in camps on the hills and are 
frequently moved ; most careful hygienic and sanitary 
precautions have been instituted. Elevation seems to 
have little effect upon the disease. Regarding the ap- 
pearance of yellow fever in the hills. General Brooke has 
telegraphed as follows to the War Department: "In 1868- 
1878 Board of Health, Santiago, reported yellow fever 
1000 feet above sea-level; in Mexico, Cordova, 2962, 
at Las Aurinas, 3308. New Castle, Jamaica, 4200 
feet, has been visited several times, and several places 
in Peruvian Andes, 4000 feet, have been afflicted with it. 
Everything is being done that can be to control the dis- 
ease." Commenting on this fresh outbreak in Cuba, 
General Sternberg says that it was not unexpected by the 
War Department. "Cuba is an infected island and this 
is the yellow-fever period." 

Medical Officers Selected for the Philippines. —The 
President has completed the selection of the medical offi- 
cers to serve with the regiments of volunteer infantry to 
be organized for service in the Philippines. These ap- 
pointments, together with the former service of the ap- 
pointees, are as follows : Surgeons, with Rank of Major. 
— Ogden Rafferty, Captain and Assistant Surgeon, 
LTnited States Army, late Brigade Surgeon Volunteers; 
Charles P. Mason, Captain and Assistant Surgeon, United 
States Army, late Brigade Surgeon Volunteers; John R. 
McDill, late Brigade Surgeon Volunteers, now Acting 
Assistant Surgeon, United States Army; Frank C. Arm- 
strong, late Surgeon Twenty-first Kansas Volunteers; 
Thomas W. Chalmers, late Surgeon Twelfth New York 
Volunteers; Charles L. G. Anderson, late Assistant Sur- 
geon, United States Army, now Acting Assistant Sur- 
geon, United States Army; D. Albert Lieberman, late 
Surgeon Sixth Missouri Volunteers; Joseph N. Henry, 
late Surgeon Fourth United States Volunteer Infantry. 
Assistant Surgeons, with Rank of Captain. — John R. 
Hereford, late Surgeon First Missouri Volunteers; 



James C. Miner, late Surgeon First Arkansas Volunteers; 
Frank W. Foxworthy, late Assistant Surgeon One Hun- 
dred and Sixtieth Indiana Volunteers; Abram L. Haines, 
late Surgeon Two Hundred and Third New York Vol- 
unteers; James J. Etwin, late Assistant Surgeon Tenth 
Ohio Volunteers ; W. E. Parker, late Acting Assistant 
Surgeon, United States Army; James E. Shellenberger, 
late Surgeon Third Ohio Volunteers. Assistant Sur- 
geons, -with Rank of First Lieutenant. — William H. 
Cook, Acting Assistant Surgeon, United States Army; 
Lomax S. Anderson, late Assistant Surgeon Fifth United 
States Volunteer Infantry; Leonard K. Graves, late As- 
sistant Surgeon Two Hundred and First New York Vol- 
unteers; Ralph S. Porter, late Assistant Surgeon Second 
Illinois Volunteers; John A. Metzger, Acting Assistant 
Surgeon, United States Army ; Patrick J. McKenna, late 
Assistant Surgeon Second United States Engineers ; 
Albert H. Aber, late Assistant Surgeon Thirty-hfth 
Michigan Volunteers; John E. Boyd, late Captain Sec- 
ond South Carolina Volunteers. 



CORRESPONDENCE. 



OUR PHILADELPHIA LETTER. 

[From Our Special Correspoudent.] 

LEGAL STEPS TO BE TAKEN AGAINST THE CHRIS- 
TIAN SCIENTISTS — INJURIES DUE TO THE FOURTH 
OF JULY— STATE BOARD EX AMINATIONS— CHIL- 
DREN'S HOSPITAL — PERSONAL — HEALTH NOTES. 

Philadelphia, July 10, 1899. 
It is an encouraging sign of the times to note that in 
both New York City and Philadelphia popular feeling 
against Christian-Science "healers" has been aroused to 
such a point of antagonism by the recent manipulations 
of this sect, that in the near future radical legal measures 
will probably be enacted to wholly suppress this menace 
to health and life. The half-dozen deaths which have 
occurred during the past three weeks, in different parts 
of this country, as the result of Christian-Science "treat- 
ment, " have opened the eyes of the public to the enormity 
of this delusion, and have stimulated the medical profes- 
sion to definite action along legal lines to suppress the 
evil. The lay press is doing a good work, at least here 
in the East, in exposing the fraudulent methods em- 
ployed by these parasites of Christian profession, and the 
more the public learns of their widespread rascality just 
so much easier it will be to secure legislative support for 
laws aimed at the abolition of the practice of the Chris- 
tian-Science fad. But the educational aid of the news- 
papers must be augmented by prompt and vigorous 
action by representative medical organizations before 
successful litigation may be hoped for. County, State, 
and national societies must take action singly and with 
combined forces. In Pennsylvania the laws of the Com- 
monwealth seem to be adequate to justify immediate 
prosecutions, but in order to make haste slowly and to 
make sure of no unexpected abortion of plans. Dr. Henry 
Beates, in his official capacity as president of the State 



July 15, 1899] 



OUR LONDON LETTER. 



85 



Board of Medical Examiners, before taking legal steps in 
the matter, has requested the Attorney-General of the 
State to render an opinion as to the precise legal inter- 
pretation of the act for the regulation of medical practice 
as applied to Christian Scientists. 

If, in the opinion of the Attorney-General, this sect 
may with impunity continue to evade the spirit of the 
law, although keeping strictly within the letter, another 
law will be agitated to absolutely prohibit their prac- 
tices; if, on the other hand, his opinion is adverse to the 
Christian Scientists, immediate steps will be taken, both 
by civil injunction and by criminal prosecution. Dr. 
Beates' initiatory steps in this matter are being watched 
with a good deal of interest by the medical profession, 
and it is hoped that at last the exact status of Christian 
Science will be determined, and that drastic measures 
may be confidently resorted to for its suppression. 

Philadelphia's contribution of accidents due to the pre- 
vailing manner of celebrating the Fourth of July places 
her high up in the list of cities where patriotism seems to 
be measured by maiming and wounding and loss of life. 
Three hundred accident cases, caused by fireworks, were 
treated by the city hospitals on the Fourth, not to speak 
of the many other unreported cases, cared for at the 
homes of the celebrators, by private practitioners. Of 
course the Mayor issued a special proclamation prohibit- 
ing fireworks, but as long as his edict is not enforced by 
the police, but rather regarded with supreme contempt 
by authorities and public alike, these needless casualties 
on the Fourth will continue. In every part of the city 
preventable suffering occurred, not only among the 
would-be patriots, but indirectly among the bed-ridden 
and nervous and sick in houses. Altogether, the Fourth 
of July nowadays has degenerated into a primeval orgie 
of noise, incendiarism and slaughter. 

At the recent State Board examinations for licenses to 
practise medicine in Pennsylvania, all the candidates of the 
Eclectic school, ten in number, qualified, while ten out of 
the forty-one candidates appearing before the Homeo- 
pathic Board failed, and must be reexamined next No- 
vember, to obtain the necessary permission to practise. 
The returns of the regular examiners have not yet been 
complettd. 

A roof-garden has just been given to the Children's 
Hospital by the president of the institution, Dr. T. \V. 
Wilson, as a memorial to his sister, Mrs. Elizabeth 
Lewis. The new structure will afford fresh, cool air for 
the patients independent of the condition of the weather, 
and has been erected at a cost of $5000. 

The total number of deaths in Philadelphia during the 
present week was 435, an increase of 1 5 over those of last 
week. Of the whole number of deaths, 189 occurred in 
children under five years of age. The returns of infec- 
tious diseases show 53 new cases of enteric fever, with 9 
deaths; 50 new cases of diphtheria, with 11 deaths; 36 
new cases of scarlet fever, with i death ; and 4 new cases 
of cerebrospinal meningitis, with 3 deaths. The small- 
pox outbreak seems to have been entirely eradicated, no 
new cases having been reported here during the past 
seven days. 



OUR LONDON LETTER. 

[From Our Special Correspondent.! 

LAWSON t.\it'.s c.^ve-burial; cause of his death; 

OTHER TRAITS— PROFESSOR SCHAEFER'S ELECTION 
AND LONDON'S LOSSES — MEDICAL REPRESENTA- 
TION IN THE SENATE AT LONDON UNIVERSITY — 
BRUSSELS MEDICAL GRADUATES IN LONDON — OS- 
LER'S lecture — POLYCLINIC DINNER — THE 
"LANCET'S" APPRECIATION OF AMERICAN MED- 
ICINE. 

London, July 3, 1899. 
That great surgical genius, Lawson Tait, seems to 
have been determined to remain as eccentric in death as 
in life. A brief clause in his will directed that his body 
should be cremated and the urn containing his ashes 
placed in a niche in a beautiful cave in the grounds of his 
country-house in Wales, known as Gogarth Cave. Over 
the niche a simple slab is to be placed, bearing nothing 
but his name and age, and a short inscription to the ef- 
fect that his life had been devoted to the attempt to save 
the medical profession from the shameful folly of animal 
experimentation and the delusion that the results so ob- 
tained were of any value in human medicine. It is ex- 
traordinary how many really great men seem to prefer to 
be remembered by their weaknesses, or even their follies, 
instead of by their real masterpieces. To think of a 
genius emblazoning upon his tombstone only the deeds for 
which he needs forgiveness — and oblivion ! His other 
directions though equally unique, had a simple dignity 
about them which commands our respect and sympathy. 
No public gathering was to be held at his interment, or 
ceremonial of any kind, religious or otherwise, in fact 
only the members of his family were to know the date at 
which it occurred. These were observed to the letter. 
His body was taken to Liverpool by his brother-in-law 
and two executors, cremated, and the urn delivered to his 
widow, who, there being no issue, will alone and unac- 
companied place it in the grotto, after such an interval as 
she judges best. 

The cause of his death was renal calculus, probably 
causing a rupture of the ureter, as death came within 
twelve hours of the first symptom of trouble. He had 
had several attacks of renal colic, and two years ago an 
operation had been performed for the removal of a calcu- 
lus from the urethra, so that, as his will clearly shows, 
the great surgeon was fully aware that serious complica- 
tions might develop at any moment. 

From his student days in his native Edinburgh to the 
very week of his death Lawson Tait loved fighting for its 
own sake, and when the "fog uv fightin' " was on him 
was perfectly reckless who or what he attacked, so that 
there was no need for him to study the gentle art of ma- 
king enemies ; they rose in swarms on every hand, but 
nearly all of them gave him credit for sincerity, bravery, 
and a remarkable dexterity with his weapons. And some 
of his most slashing attacks, as for instance, that upon 
the over-theoretical and over-scientific tendencies in 
modern medical education, with regrets for the departure 
of the old apprenticeship system, when at an association 
meeting at Birmingham, he advised his surgical brethren 
not to waste their time in the surgical exhibit but to ob- 



86 



TRANSACTIONS OF FOREIGN SOCIETIES. 



[Medical News 



serve and endeavor to imitate the dexterity of the Brum- 
magem button-cutter, had a great deal of wholesome truth 
under their ferocity. 

The chair of physiology in the University of Edinburgh 
has at last been filled by the election of Professor Schafer 
of University College, London. This selection will meet 
with the unanimous approval of the entire medical profes- 
sion, and considerable relief is expressed here as it was 
feared that the delay was due to some feeling in the board 
of electors in favor of a local candidate. It is, however, 
a far from creditable comment upon the absence of public 
spirit and the hand-to-mouth condition of affairs in both 
medical and university education in London that the 
metropolis of the world has lost w'ithin the past three 
months her leading pathologist, one of her best-known 
biologists, and her only distinguished physiologist to little 
Cambridge and poverty-stricken Edinburgh, simply be- 
cause she is too stingy to pay them a decent salary. 
There is scarcely a chair of anatomy or physiology in 
London which has a respectable living attached to it. 
Most of them are in the antediluvian position of mere 
stepping-stones to surgery and practice of medicine. Only 
a week ago the "promotion" of a man who had begun to 
win a wide reputation as a scientific anatomist to the as- 
sistant lectureship in surgery was announced in the jour- 
nals. That means, of course, the end of his prospects as 
a scientist, and the beginning of his degeneration mto a 
mere operative-surgeon. 

The composition of the senate of the proposed Univer- 
sity of London has just been announced. Of its members 
12 are to represent science, lo the arts and literature, 6 
medicine, while music, law, and theology have one each. 
Perhaps this may furnish at least the really great and ad- 
equately supported medical school which is so badly 
needed, but so intense is the conservatism, and so in- 
numerable the petty jealousies and bickerings with which 
the scheme has to contend at every step, that it will be a 
matter of years or even decades before any actual 
teaching can be hoped for from it. 

The annual dinner of the Brussels Medical Graduates' 
Association is announced for July 5th. It might at first 
sight appear strange that there should be a sufficient 
number of Belgian graduates in London to form an asso- 
ciation, but the clue to the mystery is that the English 
degree of M.D. is so expensive and so outrageously diffi- 
cult to procure that a large number of medical men go 
over to Brussels, where the coveted degree can be ob- 
tained by one-year's residence and study. There is a 
strong and growing desire here to resort to American 
medical colleges for this purpose. 

The General Medical Council has published a brief but 
complete and continuous story of the Hunter persecution, 
in which it magnanimously forgives its victim and admits 
that its Penal committee may have been a trifle over- 
zealous, but that nobody in particular was to blame, ex- 
cept, perhaps, poor Hunter himself, in placing his sign 
door-plate where the committee could see it when it hap- 
pened to have its "fighting-socks" on. 

The inaugural dinner of the London Polyclinic was a 
great success. Nearly 300 guests were present, repre- 



senting the flower of English medicine, and the treasurer 
was able to announce at the close that the funds of the 
institution had reached the sum of nearly $25,000 and 
that some 200 students and attenders had enrolled them- 
selves for the first term. Sir John Lubbock was in the 
chair and speeches were made by Sir. William Broadbent, 
Sir Joseph Fayrer, Mr. Jonathan Hutchinson, Dr. Wil- 
liam Ord, and others. 

The event of the week attracting the widest interest 
was the Cavendish Lecture of Professor Osier of Balti- 
more, before the West London Medical Society. An 
audience of nearly 400 physicians attended and the lec- 
ture was published in full in the current number of both 
fie Lancet and the British Medical Journal. A curious 
little incident occurred during the proposal of the cus- 
tomary vote of thanks, which much amused the Ameri- 
cans present. The mover of the vote was enumerating 
the various grounds for welcoming Dr. Osier, and 
claimed him first as a Canadian and fellow-subject of the 
Empire, which evoked a mild ripple of applause, then as 
a representative of ' 'our brethren across the Atlantic, the 
great American medical profession," and the speaker 
had to wait until the applause subsided before he could 
go on. 

The Lancet devotes a long editorial to a critical com- 
mendation of Dr. Wilson's address at Columbus. It re- 
gards his estimate of the achievements of American 
medicine both just and moderate, scores deservedly a 
certain class of our journals, and cordially endorses his 
proposal to appoint a Minister of Public Health. 



TRANSACTIONS OF FOREIGN SOCIETIES. 

German. 

A FAMILY WITH CVSTINURIA — APPENDICITIS "LAR- 
VATA" — DIFFERENCE BETWEEN EPIDEMIC AND 
SPORADIC CASES OF CEREBROSPINAL MENINGITIS — 
MISTAKES IN DIAGNOSIS AFTER RUPTURE OF THE 
GALL-BLADDER — ENDOVESICAL PHOTOGRAPHS. 

At the Berlin Medical Society, May 10, 1899, Cohn 
described a case of cystin calculus of the bladder which 
occurred in an eight-year-old girl. The stone w-as re- 
moved suprapubically and the child recovered. The in- 
teresting feature of this case was the fact that the mother 
of the child and five other children also at various times 
passed urine containing cystin, while the father and two 
grown sons always passed urine which was free from it. 
The occurrence of cystin in the urine of several members 
of one family was noted many years ago, but no such re- 
markable coincidence as this one has before been re- 
ported. 

May 17th EwALD spoke of a type of appendicitis 
which he designated by the name "larvata." The symp- 
toms are those of disturbed intestinal action with blood 
and mucus in the stools, and also loss of appetite and 
indigestion. The trouble goes on for years, sometimes 
better and sometimes worse, and usually the diagnosis is 
not made for a long time. When questioned the patient 
will admit having had a good deal of pain in the region of 
the appendix and ascending colon, and upon operation 



JULV 15, 1899] 



NEW YORK ACADEMY OF MEDICINE. 



87 



these structures will be found to be much thickened. It has 
been suggested that the sudden improvement which fol- 
lows an operation of this character does good by sugges- 
tion. Ewald was sure that this was not the true explan- 
ation in his own experience, for three reasons : All his 
patients so operated upon were not hysterical. They 
may have been nervous on account of the long-continued, 
painful attacks, but not hysterical. In the second place 
the suggestive effects of an operation, though they may 
be immediate and striking, wear off after a while and the 
old symptoms return. This was not true of his patients 
as some of them had remained well for over five years. 
But the strangest proof of all, that the effects of operation 
were not suggestive, is that patients who had painful 
sjTiiptoms due to disorders of the stomach or intestine 
continued to have the same symptoms after those refera- 
ble to the appendix had disappeared. 

Senator objected to the use of the term larvata in 
this connection. The cases of appendicitis to which the 
speaker had referred were not lar\-ated in the sense that 
malaria may be, and nothing was to be gained by calling 
them so. They were, properly speaking, cases of appen- 
dicitis in which diagnosis was difficult. 

At the Union for Internal Medicine, May 15th, Stad- 
ELM.4NX spoke of the difference between epidemic and 
sporadic cases of cerebrospinal meningitis, having recently 
treated a case of the latter with success. The patient was 
a young man, and although at one time he was comatose, 
with Cheyne-Stokes respiration, and a thready pulse, he 
fully recovered. Several lumbar punctures were made, 
not for their therapeutic value, but to establish the diag- 
nosis and to note the progress of the disease. As the 
case progressed toward recover)- the turbidity of the fluid 
grew to be less and there was a destruction of the pus- 
corpuscles. The fluid contained a short rod-like ba- 
cillus. 

At the Imperial Society of Physicians of Vienna, May 
13th, HOCHENEGG presented a patient, a female aged 
forty-seven years, who had suffered from symptoms of 
intestinal obstruction, immediately after an intense ab- 
dominal pain. There was a doughy tumor at the um- 
bilicus, and a diagnosis of volvulus of the transverse 
colon was made. Laparotomy was performed, and 
about six quarts of bile-stained fluid was washed out of 
the abdominal cavity. An old distended gall-bladder 
had ruptured. 

Fabricius mentioned three cases of rupture of the 
gall-bladder in which a correct diagnosis was not made. 
In the first, on account of the umbilical swelling, a 
hernia was thought of ; in the second, the tumor was so 
hard that it was mistaken for a fibroma ; while in the 
third case, the escaped fluid penetrated the sheath of the 
rectus muscle and set up an abscess. 

At the Vienna Medical Club, May loth, Lang showed 
photographs of vesical mucous membrane taken during 
life by means of an improved cystoscope, his own modi- 
fication. The actual negatives were about 3 mm. in di- 
ameter, but they were enlarged about ten diameters, so 
as to make it possible to see details more clearly. The 
instrument also prevented any trembling, which is cer- 



tain to spoil a photograph of this sort. The instruments 
were sterilized by exposure for an hour and a half to 
formalin vapor. 

SOCIETY PROCEEDINGS. 



THE NEW YORK ACADEMY OF MEDICINE 

Stated Meeting, Held Thursday, June I, iSgg. 

The President, Dr. William H. Thomson, in the 
Chair. The paper of the evening was by Dr. Henry 
D. Chapin, and was entitled "The Treatment of Sum- 
mer Diarrhea in Infants" (see page 65). The discus- 
sion was opened by Dr. L. Emmett Holt, who said in 
brief : The most important consideration as regards the 
lessening of the death-rate from diarrhea among infants 
in our large cities in the summer time is the matter of in- 
telligent prophylaxis. For this the most practical means 
at hand would seem to be the dissemination of literature 
among the ignorant classes. In the tenement-house district, 
especially, is the information scattered by leaflets con- 
taining definite directions as to the feeding and care of 
children in the hot weather of special importance. There 
is no doubt in the minds of any who have had experience 
in this matter of the great possibilities for good that are 
contained in this work. 

Dispensary practice among the very poor ser\-es to 
show how extremely necessary seemingly the most ob%4- 
ous information on such matters is. The most ludicrous, 
if they were not so serious and apt to be so fatal, mis- 
takes are made by mothers who might easily be expected 
to know better. The distribution of a leaflet containing 
the necessary directions as to the care of children in sum- 
mer was contemplated two years ago, but for some 
reason the idea was abandoned. It is to be hoped that 
the New York City Board of Health will again take up 
the work in this line, for there is not the slightest doubt 
that great good can be accomplished in this way. 

As to the actual treatment of diarrheic conditions time 
is the most important element for their cure. If they can 
only be treated i-.i time there is but very little danger. 
Twelve hours is more precious for therapeutic purposes 
at the beginning of the sickness than is a whole week of 
medication later on. The trouble is, however, that be- 
ginning diarrheas are neglected. They are attributed to 
teething, to a cold, to the weather, and it is thought they 
will get better of themselves or with some simple house- 
hold remedy, and with some slight modification of diet. 
In twenty-four hours, perhaps, a fatal diarrheic condi- 
tion that defies all treatment is lighted up. Four or more 
movements a day in the child are allowed to occur 
for some days without seeking relief for them. The in- 
fection gains a firm hold by irritation of the intestine, 
and then cannot be eradicated before it has produced 
serious eftects. 

In children with whom simple milk does not agree the 
dilution of the proteids of the milk by some carbohydrate 
is often of great service as a prophylactic against diar- 
rhea. A number of the cereals may be used for this pur- 
pose, and there is no doubt that they have a good effect. 



88 



NEW YORK ACADEMY OF MEDICINE. 



[Medical News 



Arthur Keller has shown by a recent series of experi- 
ments that in vitro, at least, the presence of carbohy- 
drates prevents the putrefaction of proteids. We thus 
get a scientific confirmation of what we have known for 
a long time clinically to be the case, that intestinal putre- 
faction of milk is prevented by mixture with cereals. 

Once the diarrheic condition has asserted itself there 
should be no hesitation as to taking radical measures. 
Mere modification of diet will not suffice. The practi- 
tioner is tempted to temporize, and hopes that the condi- 
tion will not prove serious. This is always a serious and 
may prove a fatal mistake. Stop all food at once until 
there is a decided improvement m the intestinal condi- 
tion. The indication is to get the stomach and intes- 
tines empty as soon as possible. For this irrigation of 
the intestines is the best therapeutic means, not once 
only, for after the lower bowel has been washed out for 
some hours, other material comes down into it, and this 
too may be removed, and some of the toxic absorption 
and a certain number of the intestinal micro-organisms 
be gotten rid of. In ordinarily severe cases irrigation 
may be practised four or five times a day. In bad cases 
when the temperature runs up to 105° F. the intestines 
should be irrigated every two hours, at first with warm 
water (100^ to 105° F.) to get its cleansing, relaxing ef- 
fect, and then with cooler water to help bring down the 
temperature. Washing out the stomach is also good, es- 
pecially at the beginning of an attack. 

All food should be stopped absolutely for twelve hours 
or longer. Water may be given freely, and stimulants 
are often good. It must be remembered that even sterile 
milk does not stay sterile long in an infected digestive 
tract, and that its presence only irritates, while the milk 
itself forms an excellent culture medium for the growth 
of micro-organisms that are present. 

Dr. Abraham Jacobi said that there are times when 
one feels that one has not lived in vain. Such occasions 
almost compensate, though they are seldom enough, 
alas, for the number of times when one feels that one has 
accomplished nothing. It is refreshing, indeed, to hear 
the recommendation to mix cereals with milk given so 
freely after one has been teaching the doctrine for 
thirty to forty years. Years ago he counselled the sus- 
pension of the casein of the milk in oatmeal or barley- 
water by proper dilution. It certainly produces a more 
flocculent curd. Of late years the idea has been taken 
up very enthusiastically in certain parts of Europe. Pro- 
fessor Heubner, for instance, who holds Henoch's chair 
at Berlin, has taken up the matter of the mixture of milk 
with cereals, and is teaching it very emphatically. 

With regard to leaflets to be distributed to the poor 
containing instructions for the feeding of infants, he 
believes very fully in their usefulness. More than 
twenty-five years ago at the request of the New York 
Board of Health he prepared such a leaflet, and for nearly 
twenty years it was regularly distributed. About five 
years ago its further dissemination was given up for some 
unknown reason. There is only one thing in the old 
leaflet that it would seem desirable to change and that is 
the direction to add bicarbonate of soda to the milk when 



it cannot be procured fresh. Adding to the alkalinity in 
this way only makes the milk a belter culture medium 
for micro-organisms and this should be avoided. 

It IS not by any means a new observation that the 
presence of carbohydrates prevents putrefaction. It has 
been known that they readily undergo fermentation 
and that in this process free acids are formed. The 
presence of free acid acts as an inhibitory agent to the 
microbes that produce putrefaction. The use of cereals 
in baby-food is then at once a preventive and a cura- 
tive agent in certain intestinal disorders. 

It has long been the custom to say that no amylaceous 
substances should enter into a young infant's food because 
it has from nature at an early age no ferment capable of 
digesting starch. Even admitting this, however, the ad- 
dition of carbohydrates to the child's dietary supplies a 
certain amount of ballast to artificial food. In mother's 
milk this ballast is provided mainly in the fat which con- 
stitutes 10 to 12 per cent, of the excrement of nursing 
babies. It is not true, however, that even very young 
infants have no ferment capable of digesting starchy ma- 
terial. The saliva of a newly born child, and it is wrong 
to say that there is no saliva at this age, will dextrinize 
starch as any one who wishes may prove for himself. 
That the parotid gland of a healthy fetus after three months 
of age contains an amylolytic ferment has been proven 
over and over again. The submaxillary gland contains 
a similar ferment to that in the parotid gland from the 
beginning. Starch digestion is then very natural to the 
infant and the mixture of this material in artificial food 
provided for it is indicated at all ages. 

Dr. Koplik said that he thought preventive measures 
should be more insisted on than had been the case in the 
discussion, and especially that summer diarrheas should 
be treated rigorously in their very earliest incipitncy. A 
slight frequency of stools, especially if they are of watery 
consistency and if accompanied by the slightest inclination 
to vomit, should be the signal to stop all feeding at once. 
Then the bowel should be promptly cleaned out and the 
stomach also if thought advisable. The one thing that 
must be the doctor's object is to prevent the development 
of serious diarrheas. Very little can be done for the 
severer forms of the affection and prophylaxis is our only 

hope. 

Here in New York City we are at le.ist twenty hours 
away from our milk-supply, so that there is no hope of 
getting anything like fresh milk. Under these circum- 
stances he was surprised that the necessity for the sterili- 
zation of all milk to be given infants had not been not more 
insisted on by the preceding speakers. After thorough ster- 
ilization the milk should be cooled rapidly in order to pre- 
vent the separation of the cream from it to too great ex- 
tent. Pasteurized milk though much confidence had been 
placed in it for the prevention of summer diarrheas has 
not been found satisfactory. It is liable for reasons 
not well understood just yet to set up slight diarrheic con- 
ditions and cause some gastro-intestinal irritation so that 
its use is not advisable. 

As to the mixture of a certain amount of the cereals 
with milk for infant feeding his opinion accords more 



July 15, 1899] 



THE AMERICAN ORTHOPEDIC ASSOCIATION. 



89 



or less with what had been said by others. The current 
of medical sentiment is settling in this direction. In 
some cases certainly they give excellent results, in others 
they are very disappointing. There seems to be no spe- 
cial method of deciding in any given case whether they 
will ag^ee with the little patient or not so that the only 
thing is to try their effect and note the results. 

As to drugs very little dependence can be placed on 
them in the severe diarrheas of the summer time. When 
a practitioner thinks that he does a great deal of good 
with drugs he is evidently not an acute chnical observer. 
Divided doses of calomel are often claimed to be 
of service, but of late years he has learned to distrust 
any specific action this might have through its effect on 
the biliary secretion, or because of its supposed intestinal 
antiseptic effect. Opium he would never advise. It 
sometimes does some good by quieting the child, but 
should be given only in very small doses. It is better to 
have a restless child than one in whom opium helps on a 
fatal stupor. 

In a severe case of summer diarrhea the first indication 
is to wash out the stomach, remove fermenting material 
and prevent the absorption of toxic materials from the 
gastro-intestinal tract. This lavage need not be repeated. 
The intestines should be washed out frequently, however. 
It removes peccant material ; it stimulates peristalsis, which 
also helps to remove undesirable irritating substances, 
and it supplies water to the infant, a very useful measure 
since it is well known that the child is water-star\-ed. A 
stiff rubber rectal tube, such as is used for adults, may be 
used without fear. Too much pressure should not be 
employed, however, in forcing water into the intestines 
as it is possible to burst them. The irrigator should not 
be placed more than one foot above the patient. It is a 
good plan to try and leave considerable water in the in- 
testine when the irrigation is concluded. About a pint 
of normal salt solution should be employed. This is ab- 
sorbed belter than simple water and besides is less irri- 
tating. After improvement begins it is not easy to go 
back to milk at once. At first it should be well diluted 
to msure its not setting up a relapse to the former condi- 
tion. 

Dr. Graham Lusk detailed some observations that 
he had made on young pigs. Beginning when they were 
two days old he had fed them on skimmed cow's milk. 
To a certain number he gave only cow's milk skimmed, 
to others skimmed milk to which two per cent, of sugar 
was added, to others skimmed milk with two percent, of 
de.xlrose. Those fed only on skimmed milk did not 
thrive. They were thin and scraggy looking and failed 
to grow properly. Those fed with skimmed milk and 
sugar did reasonably well, while those fed also on 
dextrose grew vigorously. This substance is a cereal 
product, so that these recent observations would seem to 
confirm Dr. Jacobi's long-standing opinion as to the value 
of cereals, when added to milk, for the feeding of the 
verj- young. 

In closing the discussion Dr. Chapin said that despite 
certain prejudices in the matter that are rather widespread, 
a certain small amount of cereais does not cause, but 



rather checks diarrhea. They are not, it is true, as Dr. 
Koplik said, always effective, but milk diluted with 
oatmeal or barley-water always is tolerated better than if 
diluted with plain water. He thinks that as a rule pas- 
teurization suffices to make milk safe for infant consump- 
tion. In very hot weather it is safer to sterilize. It 
must be remembered, however, that it is not enough 
merely to stop fermentation in the milk and that the de- 
struction of the microorganisms in it makes it fit for use. 
If the milk is old and fermenting processes have been 
going on in it for some time changes have been made in 
the substance of the milk that may make it unfit for use. 
It would be a great advantage if we could obtain fresher 
milk in this city than at present ; if instead of receiving 
milk 20-24 hours old, or even older, we could obtain 
milk 10-12 hours old. This constitutes a field for the 
most serious effort and one in which successful effort will 
be most fruitful in saving the lives of city children. 



THE AMERICAN ORTHOPEDIC ASSOCIATION. 

Abstract of the Proceedings of the Thirteenth Annual 

Meeting, Held at New York, May JI, and 

June I and 2, i8gg. 

The president, Dr. W. R. Townsend of New York, 
opened the meeting with the reading of the annual ad- 
dress. He reviewed the history of orthopedics in America 
and showed that the profession of New York City had 
been mainly instrumental in bringing about the improve- 
ments in this branch of surgery in America and through- 
out the world. Four names especially stand out: James 
Knight, the philanthropist ; Charles Fayette Taylor, the 
mechanical genius and enthusiastic leader; Lewis SaxTe, 
the impressive teacher and eminent author ; and Henry 
G. Davis, who revolutionized the treatment of joint and 
spinal disease and whose originality and genius made him 
the father of American orthopedic surgery. 

Dr. E. H. Bradford of Boston then read a piper, 
entitled "In Memoriam of Dr. Charles Fayette Taylor," 
in which he referred to Dr. Taylor as the founder of modem 
practical orthopedics and said that every meeting of the 
American Orthopedic Association is and would ever be a 
tribute to his work. 

The next paper, on "Degeneracy as a Causative Factor 
in the Production of Scoliosis " by Dr. John Ridlon of 
of Chicago, will appear in a subsequent issue of the 
Medical News. 

Dr. E. G. Brackett of Boston then read a paper 
prepared by himself and Dr. E. H. Bradford, entitled 
"The Forcible Correction of Lateral Curvature." He 
said that it is well known that even bone will yield to 
continuous pressure. The difficulty has l)een the reten- 
tion of affected parts in positions in which pressure could 
be exercised. When the patient is in the recumbent 
position the advantage of the superincumbent weight is 
lost as an aid. A properly fitting and applied apparatus 
can be made to avail itself of this. The cast should be 
applied in a Bradford frame, which enables one to do 
away with the disadvantage of the superincumbent weight 
and use it as a corrective. 



90 



THE AMERICAN ORTHOPEDIC ASSOCIATION. 



[Medical News 



Pressure should be applied at three points, particularly be- 
hind, of which that of greatest deformity is the principal 
one, and others above and below while counter-pressure is 
exercised on points on the opposite side ol the body. 
The great objection to the use of jackets in scoliosis is 
that the point of greatest counter- pressure is over the 
concavity of the curve of the deformity on the opposite 
side. The tendency this has to emphasize the deformity 
may be corrected by a collar around the neck that takes 
up most of the counter-pressure. 

The cases for which forcible correction with retention 
as far as possible in the corrected position is necessary 
are those in which there is bony change and in which 
bony development is still expected. The greater the 
deformity the more is this method indicated. It 
serves a very useful purpose in children who are too 
weak for gymnastics, or who are not sufficiently 
under control to be put through regular exercises. The 
amount of correction that follows three or four applica- 
tions of the jacket is often wonderful. After the primary 
improvement, however, there is a period of comparative 
standstill during which other methods may be used with 
advantage. 

Dr. Teschner of New York followed with a paper, 
entitled "The Hea\'y weight Treatment of Post-paralytic 
Deformities, Including Lateral Curvatures." He has 
had six cases in which he has been able to restore func- 
tion to seemingly degenerated muscles by graduated ex- 
ercises so arranged that finally eight- to ten- or even fif- 
teen-pound dumbbells were employed. He has the 
patient, with frequent rests, put forth each time all the 
strength he is capable of. Three of his cases were ob- 
stetric hemiplegias with atrophy of muscles, yet a great 
deal of improvement took place. Reaction of degenera- 
tion in muscles disappeared during the course of the ex- 
ercises and were replaced by normal muscular reactions. 
He considers that the muscular fibers intact in the muscle 
are developed to their fullest extent, and that there is 
under the stimulus of exercise an actual development of 
muscle substance. 

Dr. Walter Truslow then read a paper, entitled 
"Some Remarks on the Class Method of Gymnastic 
Treatment in Lateral Curvature," which will appear in a 
subsequent issue of the Medical News. 

Dr. Augl'STUS Thorndike of Boston read a paper, 
entitled "Congenital Deformities of the Spine." He dis- 
cussed the two forms, spina bifida and rachischisis, and 
exhibited illustrations of the various forms, and of their 
association with forms of anencephalus, meningencephal- 
ocele, and other congenital abnormalities. Before oper- 
ation the tumors need to be carefully protected from abra- 
sion and infection. There are two practically absolute 
contraindications to operation, marasmus and the pres- 
ence of hydrocephalus as a complication. 

Rupture of the sac is usually enough to justify immedi- 
ate operation as infection is almost sure to follow. Con- 
vulsions, if due to internal pressure, may sometimes be 
relieved by puncture and evacuation of the sac, but this 
gives but temporary relief and is usually employed only 
in acute cases where the operator is not ready for more 



radical measures. Two methods of radical cure are em- 
ployed, excision and the injection of iodin. E.xcision is 
the ideal operation. Iodin has undoubtedly cured cer- 
tain forms of simple meningocele, but it is so difficult to 
distinguish them from the others that excision is pref- 
erable. 

Dr. L. a. Weigel of Rochester, N. Y., then read a 
paper, entit'ed "The Diagnostic Value of Radiography in 
Orthopedic and General Surgery, Illustrated by Stereop- 
ticon Views." He showed tnat it is possible to detect 
even small foci of tuberculosis of bone by the X-rays. In 
the head of the tibia and in the os calcis by a number of 
views it was demonstrated that lighter areas due to 
porosity of the bone occurred in the radiograms, when 
there was only tenderness and usually no swelling pres- 
ent in the vicinity. In hip-joint disease he has found the 
pelvis on the side of the lesion markedly smaller and 
atrophic as compared with the other side. 

In a series of injuries in which at the time no evidence 
of fracture could be obtained, yet serious deformity fol- 
lowed, the Rontgen-rays had shown various bony lesions, 
a fracture of the olecranon, a comminuted fracture of the 
acromion, fractures of the styloid process of the radius, 
followed by the throwing out of a large amount of plastic 
material, etc. In a case of supposed forcing of the tibia and 
fibula apart the astragalus had been found comminuted. 
Fractures of the neck of the os calcis were demonstrated 
in obscure cases. Fibrous deposit between joint surfaces 
can be detected even in such obscure situations as the 
lower jaw. Gonorrheal rheumatism in some cases pro- 
duces a change in the periosteum and ends of the bones 
that may be demonstrated in the same way. Spontaneous 
dislocation of the hip such as occurs in typhoid was illus- 
trated and its progress demonstrated. 

Dr. W. Burton Hopkins followed with a paper on 
"Pigeon Toe." He considers that there are quite a 
number of cases of this deformity amenable to direct 
treatment. As a rule parents consider this turning in of 
the toes at first in the child as they do a stoop or a sway- 
ing of the back, as a childish trick. In some cases one 
toe turns in much more than another. For these he has in- 
vented an instrument which turns the toe outward just as 
the heel comes down. At first he employed a spring set 
in the heel of the shoe ; now he has modified the instru- 
ment so that it works on ball-bearings and is practically 
indestructible. 

The report of the Committee on Recording Lateral 
Curvature was to ihe effect that photography constitutes 
the best method available at present for recording these 
spinal deviations, the method least open to error because 
of the personal equation, the one that is easiest to make 
and can be best understood by the general practitioner as 
well as the specialist without difficulty. As a means of 
controlling photographic records the method recom- 
mended by Kirchoff and somewhat modified by Bracket is 
suggested as simple and reliable. Its essential feature is 
the dropping of a plumb-line from the neck and measur- 
ing the distance of various parts of the scoliotic curve of 
the spines of the vertebras from it in the various regions. 

On motion of Dr. Wilson of Philadelphia the report 



July 15. 1899] 



THE AMERICAN ORTHOPEDIC ASSOCIATION. 



91 



of the committee was accepted, but no method of record- 
ing lateral curvature was recommended by the Association 
because none as yet described seems sufticiently definite 
and accurate. 

Dr. Joel E. Goldthwait of Boston read a paper, 
entitled "A Study of Pott's Paraplegia as Affected by 
Correction of the Spinal Deformity." In eleven cases he 
has found that correction of the deformity has always 
been followed by immediate disappearance, i.e., within a 
few hours or less of the paraplegic symptoms. The im- 
provement has persisted in all the adult cases, though 
there has been some recurrence of symptoms in children. 
No force other than the patient's own weight was used m 
securmg the correction. 

Dr. Goldthwait then read a paper, entitled "Osteo- 
arthritis of the Spine, with Report of Nine Cases." Os- 
teo-arthritis of the spine or spondylitis deformans is really 
only the spinal form of a disease that may e.xtend to all 
the joints. So far thirty- five cases under different names 
have been reported in the literature. To these the 
speaker adds nine. 

The typical symptom is the rigidity of the spine which 
may begin in spasm of the muscles and then gradually 
ends in a fusion of the vertebrae. The ribs may become 
involved and the whole thorax become immovable when 
respiration will be entirely diaphragmatic. Improvement 
often occurs after the disease has reached its acme. 

Certain text-book declarations as to the disease are not 
borne out by careful study of the cases. It is not exclu- 
sively a disease of the old but occurs oftenest in early 
middle life and not infrequently in closing adoles- 
cence. It is not limited to the large joints as is often 
stated but may involve the fingers. It may not give the 
characteristic deformity of kyphosis or scoliosis but may 
make the spine rigid with all its curves preserved. 

In the group of cases that are usually supposed to 
come under the head of spondylitis deformans there are 
really either two distinct diseases or two very diver- 
gent types of the same disease. The one form is more 
properly designated a rheumatoid arthritis and is atrophic 
in character and leads to the disappearance of portions of 
the normal joint ; the other is a productive osteitis. No- 
dular projections occur on the long parts and these fuse 
together producing the anchylosis that is noted as such a 
prominent sign of this type. 

As to the cause of the ailment in either of its forms 
nothing is definitely known. Gonorrheal rheumatism 
and other unusual forms of arthritis have been thought to 
be responsible for it, but their etiological connection is 
not proven. Dr. Goldthwait finds in his own cases and 
in certain ones reported in the literature that patients sub- 
jected to extremes of temperature are especially liable to 
suffer from it, firemen, stokers, engineers, and the like. 
As to treatment, stimulating baths are good, but fre- 
quent hot baths, though employed by some, are debilita- 
ting and do harm. Regarding hot-air treatment the same 
is true ; it must not be employed so much as to weaken 
the patient. 

Dr. G. G. Davis of Philadelphia read a paper, en- 
t'tled "Operative Treatment of Congenital Dislocation of 



the Hip." He described two new instruments for ma- 
king or deepening the acetabulum in these cases; one a 
heavy spoon-shaped gage chisel, the other a half rose- 
burr, somewhat like a trephine, especially adapted for ma- 
king a shoulder against which the head of the femur 
would rest in the new acetabulum. 

Dr. W. J. Taylor of Philadelphia then read a paper, 
entitled "Report of a Case of Dorsal Dislocation of the 
Hip Occurring Spontaneously During the Course of an 
Acute Osteomyelitis of the Neck and Shaft of the 
Femur." The case was thought at first to be one of tu- 
bercular hip-joint disease ; an abscess formed and opened 
of itself. After this spontaneous dislocation upon the 
dorsum ilii took place. This led to suspicion as to the 
cause of the process, when a free incision showed that the 
original affection had been an acute osteomyelitis of the 
shaft of the femur. The process involved the bone for 
some distance from the joint, and abscesses had formed 
beneath the periosteum and within the bone itself. These 
were evacuated and thoroughly scraped, though the pa- 
tient's low condition did not allow of doing all that was 
desired in the matter. Recovery took place with four 
inches of shortening. 

The disease started at the epiphyseal line which is 
within the capsule, and rupture took place into the joint. 
Distention of the capsule was the mechanical factor fa- 
voring dislocation, and the mechanism of the lesion is ex- 
actly the same as that which takes place in typhoid. The 
practical point to be borne in mind is that relief of the dis- 
tention of the capsule may prevent spontaneous disloca- 
tion, if aspiration, or puncture, and drainage is done in 
time. In general, harm to joint structures is done by al- 
lowing distention to continue long in any joint, so that the 
advisability to removing some of the fluid should always 
be borne in mind. 

Dr. W. E. Wirt of Cleveland, Ohio, followed with a 
paper, entitled "Reduction of Congenital Hip Dislocation 
by the Lorenz Method." If taken at an early age he has 
found that very good results can be obtained by the 
bloodless method of Lorenz in the severest cases of con- 
genital dislocation of the hip. In one of his cases relapse 
occurred because no apparatus was used after two months. 
He employs a bandage with a pressure pad to retain the 
head of the femur in place. This must be worn for 4-6 
months to insure against recurrence of the deformity. 
The use of a high heel on the affected side as recom- _ 
mended by Lorenz is also of use in keeping the bone in 
place. Sometimes it is extremely hard to get the head of 
the femur down to its place, and Dr. Wirt has used as 
high as 200 pounds traction before the operation and yet 
had difficulty during the operation. The younger the 
children when operated upon the less the difficulty and 
the better the result. 

Dr. H. M. Sherman of San Francisco then read a 
paper, entitled "Congenital Dislocation of the Hip." He 
has performed eleven bloody or open operations according 
to the Lorenz method. In these the results have been as 
follows: Three are stable, i.e., the head of the femur re- 
mains in place but there has been anchylosis ; one is sta- 
ble and there is a certain amount of motion. There is also 



92 



AMERICAN ORTHOPEDIC ASSOCIATION. 



[Medical News 



a certain amount of shortening, and for some unknown 
reason this is increasing. One is stable and anchylosed and 
tlie anchylosis has been broken up giving motion, but the 
typical gait of the short-necked femur remains. Three 
luxated again and are failures. Both hips of one child 
operated upon anchylosed, causmg a very awkward gait 
which was improved by the recurrence of luxation of one 
hip. He has operated on thirteen hips by the bloodless 
method, of which seven have recurred. Lately he has 
operated with the Lorenz manipulations, but has con- 
vinced himself of the presence of the head of the bone in 
the acetabulum by an incision and actual palpation of the 
conditions. He has been better satisfied with this method 
though about one-third of them have definitely reluxated 
and a certain number of ihem are still in splints and the 
ultimate results are uncertain. He thinks there must be 
some way of correcting the deformity, but up to this we 
have not found the way. 

Dr. R. T. Taylor of Baltimore then demonstrated 
the kyphotone, a machine for the forcible correction of 
the deformity of Pott's disease. It consists of an arm at- 
tached to the upright from which the patient is suspended, 
by which pressure is brought to bear immediately over the 
most prominent part of the deformity of Pott's disease thus 
securing the greatest possible amount of correction as the 
jacket is put on. He also exhibited an inclined plane of 
nickeled steel-tubing, light and easily adjustable, and 
eminently cleanly for use in fractures and the treatment 
of deformities. 

Dr. Royal Whitman of New York then read a pa- 
per, entitled "Further Observations on the Treatment of 
Congenital Dislocation of the Hip. Exhibition of Pa- 
tients." which will appear in a subsequent issue of the 
Medical News. 

Dr. T. Halstead Myers followed with a paper on 
"Cases of Coxa Vara and Congenital Dislocation of the 
Hip. Exhibition of Patients." The case of congenital 
luxation of the hip was the first one operated on by the 
Lorenz method in this country and the result is perfect. 

Patients suffering from different varieties of orthopedic 
disease were then exhibited by Drs. Ketch, Waterman, 
Taylor, and Townsend, after which Dr. A. M. Phelps 
of New York read a paper, entitled "Report of Cases of 
Tubercular and Purulent Abscesses of Joints, Treated 
with Pure Carbolic Acid. " He said that he first washed his 
hands m pure carbolic acid and. after allowing it to remain 
for a minute, washed it off with alcohol. This he con- 
siders demonstrates that alcohol is the antidote to car- 
bolic acid locally. Taking advantage of this he swabs 
out all cavities thoroughly with pure carbolic acid, and 
then washes them out with alcohol and later with water. 
In tuberculous cases he obtains primary union by means 
of this even in long-standing suppurative cases. Where 
the patients remained in the hospital for months before 
they now stay weeks. In three or four weeks they may 
be discharged cured, while four months did not seem 
long before. 

In cases of erysipelas with high fever the effect of the 
application of carbolic and its subsequent neutralization 
had been most marked. A drop of lour to five degrees 



in temperature took place, and the erysipelatous process 
ceased to spread. In Dr. Phelps' own case when septic 
infection had set up lymphangitis the same sort of an ap- 
plication had lowered the fever, relieved the symptoms, 
and made him feel much easier. What theory explains 
this action he does not know ; perhaps there is a change 
produced in the subcutaneous layers with absorption of 
phenic or other albuminoids. The effect is certainly pro- 
duced, and there would seem to be great promise in the 
use of the remedy in the various affections mentioned. 

Dr. Arellana, Dr. Phelps' assistant at the City Hos- 
pital of New York City, read a paper on "Cases of Ery- 
sipelas with High Temperature, Treated by Applications 
of Carbolic Acid, with Subsequent Neutralization by Al- 
cohol. " In a series of some ten cases of erysipelas of the 
face and neck, with temperatures ranging from 104.5° 
to 105.5° f^-' applications of pure carbolic acid were fol- 
lowed in from eight to twelve hours by a drop of from 
3° to 5°, and the process ceased to spread. In about 
one-third of the cases a second application had to be 
made, but never a third. No other method of treatment, 
local or internal, was employed, and all of the patients re- 
covered, though it is among such that fatal cases of ery- 
sipelas are often found. In none of the cases has there 
been any smoky urine, or any change in the urinary secre- 
tion, and no sign of any carbolic-acid poisoning has de- 
veloped, though they have been carefully looked for. 

Dr. G. G. Davis of Philadelphia presented a new os- 
teoclast and a new instrument for flat feet and for paralysis 
with drop-foot to be worn inside the shoe. 

Dr. Wirt of Cleveland presented a new knee-brace 
for correcting deformity and a pocket goniometer. 

Dr. S. L. McClirdy presented a new apparatus for 
the support of the head in cervical Pott's disease with 
supports on the sternum and back below and chin and 
occipital pads above. 

Dr. H. M. Sherman of San Francisco read a paper, 
entitled "Position Symptoms in Joint Disease." He said 
in brief that the position assumed in joint affections is a 
valuable clinical symptom of the amount of inflammation 
present and the stage of the affection and has long been 
acknowledged as such. There has not been the same 
agreement as to the reason for the positions observed. 
The French explanation that the amount of the effusion 
into the joint causes the various positions by tension on 
the capsule or by its rupture late in the affection is no 
longer accepted. The idea that one sec of muscles is 
stronger than the other and that both being irritated the 
stronger fle.xors overcome the extensors supposes a strug- 
gle for superiority between muscles that does not exist. 
Dr. Sherman considers that the position assumed is due to 
the reflex call for rest for the affected parts which causes 
not a spasm but a tonic contraction of muscles fixing the 
limb in a definite position where there is least discomfort. 
When this tonic contraction relaxes for any reason, as 
during sleep, then there occur the starting pains so often 
noted. This muscular fixation is. however, but a small 
part of the mechanism as bones and ligatnents and cap- 
sular tissues share in the reflex demand for rest. 

Dr. B. E. McKenzie of Toronto read a paper, en- 



July >s, 1899] 



THE AMERICAN ORTHOPEDIC ASSOCIATION. 



93 



titled "Some Salient Points in the Treatment of Hip Dis- 
ease," which will appear in a subsequent issue of the 
Medical News. 

Dr. C. L. Starr of Toronto followed with a paper on 
"The Conservative Surgical Treatment of Tuberculous 
Disease of the Joints." He considers the ideal sur- 
gical treatment for a tuberculous focus in bone to be 
to cut down and remove it before it had invaded impor- 
tant structures and caused extensive destruction of tissue. 
The first definite focus of tuberculosis is situated at the 
epiphysis, which accounts for the fact that the very young 
and the old are not attacked. In the very young the 
hyperemia here increases the resistive vitality ; in the old, 
fatty changes have made the parts a poor culture medium 
for the bacillus tuberculosis. 

There are certain cases in which we are unable to diag- 
nose the presence of a tubercular focus before it has in- 
vaded the joint. Pain is not very valuable as a diagnostic 
sign of the position of a lesion because of its liability to 
be reflected from and referred to other points than the 
affected one along nerves. Tenderness is, however, of 
the greatest service and will very often enable one to 
diagnose with assurance. 

The indication is to open up at once and scrape away 
all the diseased bone. In the head of the tibia or in the 
malleolus this is often very feasible and can be done suc- 
cessfully in the femur. The cavity made should be 
swabbed out with carbolic acid or with chlorid of zinc and 
then packed with iodoform gauze. Healing in selected 
cases is prompt and complete. So far no recurrences 
have been noted. 

Dr. A. B. JUDSON then read a paper, entitled "Addi- 
tional Views on the Treatment of Hip Disease." He 
said that a great deal can be done to correct the gait of 
cured hip-joint disease with shortening, by training the 
patients to walk. Girls with two or three inches of short- 
ening often walk marvelously well. Boys more neglect- 
ful with less shortenmg walk very awkwardly. Military 
training and the keeping of time is a good drill for these 
children. The parents must be impressed with the idea 
that constant watchfulness and care in the matter of the 
best possible gait will lead to improvement in this matter. 
A deliberate turned step must be adopted. If this care 
of the walk is attended to the surgeon need never fear 
anchylosis in a bad position. 

Dr. S. H. McKim of Baltimore then read a paper 
prepared by himself and Dr. R. T. Taylor, entitled 
"Some Clinical Features of Rheumatoid Arthritis." 
Among the clinical features of the disease not usually 
pointed out the authors dwelt on the frequent occurrence 
of polyadenitis of the lymphatic system and enlargement 
of the spleen. The systems of glands especially affected 
are those nearest the diseased joints, theepitrochiear, the 
inguinal, and the posterior cervical. Slight exophthalmos 
often exists, and there is frequently some fever. The 
febrile course is of two types, either acute, lasting for 
but a few days at the beginning, or continuous for some 
time when it is milder. Garrod still believes that the dis- 
ease is a gouty or rheumatic manifestation, but most of 
the authorities agree with Osier, who considers it a 



nervous condition. The differential diagnosis must be 
made from subacute rheumatism, in which the changes 
around the joints are fibrous in character and not the 
nodular enlargements met with in the productive variety 
of rheumatoid arthritis. Charcot's disease occurs in older 
people as a rule, though at times, too, in young peo- 
ple, but gives clear evidence of being trophic in character. 
It must be borne in mind that the starting pains at night 
may occur in rheumatoid arthritis as well as in tubercu- 
lous joint disease and this fact must be remembered in 
making the diagnosis. Very litde seems to be accom- 
plished by any treatment. Ordinary rheumatic, alterative, 
or absorptive remedies appear not to affect the course of 
the disease or any of its symptoms. Even the breaking 
up of adhesions under ether seems to do little if any 
good. 

Dr. J. D. Griffith of Kansas City then read a pa- 
per on "A New Method of Reducing Ancient Disloca- 
tions of the Humerus by Open Incision." In three cases 
he found that by cutting the long head of the biceps the 
head of the bone slipped back comparatively easily. As a 
number of deaths have been reported from the use of 
force in these cases because of rupture of the axillary 
vein, this bit of technic seems worth bearing in mind. 
He exhibited an instrument shaped like a very large 
periosteal elevator, devised to assist in throwing the head 
of the humerus back into the glenoid fossa. 

Dr. S. L. McCurdv of Pittsburgh read a paper on 
"Heat as a Therapeutic Measure." In chronic joint 
disease bacterial growth may be inhibited by keeping the 
joint subject to temperatures of 140° F. for hours and 
metabolic processes are increased and absorption of in- 
flammatory products take place. The difficulty is that 
living tissues cannot be elevated in temperature sufficiently 
to accomplish either of these ends without hurting cell- 
life so much as to do more harm than good. 

Dr. B. E. McKenzie of Toronto read a paper, en- 
titled "Surgical Intervention in Spastic Paralysis (Cere- 
bral Palsies)." He said that these unfortunate patients, 
owing to the prevalence of the idea that the basis of their 
symptoms is a lesion of the central nervous system, and 
that nothing, consequently, can be done to permanently 
improve them, have received in the past too little atten- 
tion. He has found that all of them are benefited by 
properly directed treatment. He cuts the tendons of 
spasmodically contracted muscles and puts the limbs up 
in casts to secure elongation on union. The adductors 
he has found especially subject to contraction and after 
section he fixes the legs at an angle of 90°. Relapses 
may occur and then he tenotomizes again or does a my- 
otomy. The children are soon able to walk and their as- 
sociation with other children soon improves their mental 
qualities. They grow much more intelligent. Apparatus 
can be dispensed with after a time, or need be worn only 
at night. Training and gymnastic exercises serve to get 
the children inlo better general health. The absence of 
the reflexes set up by the continuous spasm gives the 
child an opportunity to develop physically and mentally 
in a way that is most satisfactory. 

Dr. a. B. Judson of New York then read a paper. 



94 



REVIEWS. 



[Medical N'WS 



entitled "Prothesis, a Branch of Orthopedic Practice." 
He exhibited sets of apparatus designed to hide deform- 
ity and make up for various disabilities. A perfectly nor- 
mal looking shoe for considerable shortening after hip dis- 
ease, the foot being supported on a cleverly constructed 
inclined plane within it, was the most striking. 

Dr. Daniel La Ferte of Detroit, Mich., then read 
a paper, entitled "The Cause of Failure after Phelps" 
Operation for Club-foot." In his experience failure has 
been invariably due to the fact that not enough tissue was 
divided to permit correction of the foot. Everything 
that resists the reposition of the foot to a normal position 
and a little beyond should be freely divided. This may 
require division of certain ligaments of the joints, as well 
as skin, fascia and muscles ; even the posterior ligament of 
the ankle beneath the tendo-Achillis may require division. 

Dr. Arthur Gillette of St. Paul, Minn., followed 
with a paper, entitled "The State Care of Crippled Chil- 
dren." He stated the necessity for State care for such 
children when relatives are poor, and detailed the success- 
ful effort that has been made in Minnesota in securing 
State aid for an orthopedic department. The success 
achieved has made the gaining of further State aid 
easier, and now the outlook for orthopedics for the 
needy is good. Patients are taken only on the recom- 
mendation of physicians and the manner of conducting 
the affair through the Legislature, may prove of help to 
others who have similar objects in view. 

Dr. Russell A. Hibbs of New York then read a 
paper, entitled "A Preliminary Report of a Study cf 
Shortening of the Tibia in Connection with Tuberculous 
Disease af the Hip." In a previous paper he had shown 
that in i lo cases of hip-joint disease there was distinct 
shortening of the femur. The most shortening oc- 
curred in non-suppurative cases so that it was due not 
merely to loss of bone but to nervous or circulatory causes. 
He^has now examined the tibias in 41 cases, and has 
foundjhat this bone also is shortened in most cases, and 
and in many more than the femur of the corresponding 
side. There is then a nervous or circulatory disturbance 
that interferes with the nutrition of the whole limb. 



REVIEWS. 



An Experimental Research into Surgical 
Shock. The Cartwright Prize for 1897. By George 
W. Crile, A.M., M.D., Ph.D., Professor of the 
Principles of Surgery and Applied Anatomy in the 
Cleveland College of Physicians and Surgeons. Phil- 
adelphia: J. B. Lippincott Company, 1899. 
Any experimental evidence tending to throw light 
upon our knowledge of surgical shock is a welcome ad- 
dition to the literature of the subject. Dr. Crile has ac- 
cumulated in his researches some testimony as to the na- 
ture of this most dreaded of surgical sequels, which while 
not entirely new, is, nevertheless, important on account of 
its practical bearings. 

His researches embraced operations upon animals in 
all regions of the body. Operations upon the brain and 
the abdomen seemed, under certain conditions, to pro- 



voke shock more easily than operations in other parts of 
the body, while procedures upon the male genital organs 
and dragging operations in the vicinity of the pylorus and 
gall-bladder seemed also prone to call forth this condi- 
tion. The author concludes as a result of his work that 
shock is primarily a vasomotor disturbance, influenced 
indeed by cardiac and respiratory changes. Hemorrhage 
the author finds a powerful factor in producing shock as 
it is responsible for the great change in the vasomotor ef- 
forts to maintain a mean blood pressure. The best 
treatment is prophylactic; but with the condition once 
established, the author finds experimentally that the 
usual clinical treatment with heat, strychnin stimulation, 
and saline infusions is based upon sound physiological 
principles. 

The essay is the result of hard work and a large num- 
ber of experiments and is admirably written. It de- 
serves a high place in the literature of the subject with 
which it deals. 

International Clinics. A Quarterly of Clinical Lec- 
tures on Medicine, etc., with specially prepared articles 
on Treatment and Drugs. By Professors and Lec- 
turers in the Leading Medical Colleges of the United 
States and Foreign Countries. Vol. I. Ninth series. 
Philadelphia: J. B. Lippincott Company, 1899. 

The present volume contains a most varied assortment 
of good things, and keeps up the repuiation of the Quar- 
terly for the presentation of practical material of present 
interest and actual value to the practitioner. Professor H. 
C. Wood of the University of Pennsylvania contributes 
an interesting lecture on "Cold as an Antipyretic." Be- 
sides very practical suggestions as to the use of the vari- 
ous hydrotherapeutic remedies, there is a special section 
on "Air Baths." Professor Wood says: "Sometimes 
when cold-water baths are not to be had cold air becomes 
of great value for the reduction of temperature. The 
method at least in the winter time is of very simple appli- 
cation ; the patient is covered with nothing but a thin 
sheet and the windows of the sick room widely opened 
until the temperature of the room has fallen sufficiently 
low. This cold-air treatment may be boldly employed, 
for patients with high temperatures cannot take cold. The 
thermometer must be the guide in the matter, and the pa- 
tient's temperature must not be allowed to come down 
to the normal for it is to be remembered that the room 
will remain cool for some time after the windows are 
closed. The patient should not be exposed below the 
pelvis, and the legs and feet should be well protected. 
Any disposition to coldness of the feet is an indication for 
the local application of heat." 

Professor Rosenheim's clinical lecture on "Chronic 
Constipation" is concluded, and contains some further 
very practical suggestions. This, for instance, seems 
novel on this side of the water at least. He insists on the 
plentiful consumption of fat for constipation, and sug- 
gests that when one form of fat is not well borne another 
may be ; for instance, when butter disagrees things pre- 
pared in lard may not, or when both prove indigestible 
goose lard, or some of the vegetable table oils, may prove 



JULV IS, 1899] 



REVIEWS. 



95 



palatable, produce no disagreeable symptoms, and ac- 
complish the desired result. 

Professor Eulenberg of Berlin has a very suggestive 
contribution on the "Present Position of the Treatment 
of Tabes. " while Professor Fournier of Paris presents 
some very striking views as to the "Frequency of Cases 
of Unsuspected Syphilis." 

From Professor Adolf Baginsky of Berlin there is a 
clinical report that contains a clear discussion of certain 
subjects in pediatrics that have attracted a good deal of 
attention in recent years: "Laryngospasm, Eclampsia, 
and Tetany in Children; Their Connection with Rachitis, 
and with One Another." Rachitis is generally conceded 
by pediatrists abroad to be the common basis from which 
the three symptom complexes mentioned take their origin. 
Incidentally, the interesting question as to the influence of 
an enlarged thymus in causing laryngospasms in children, 
and sometimes causing sudden death is discussed. 
Among the causes of sudden death in children mentioned 
is the lymphatic condition for which Professor Baginsky 
fails to see the necessity for creating a special rubric, as 
the cases included under it are only the outspoken exam- 
ples of the scrofulous diathesis with which all physicians 
are familiar and for which a special name is not needed. 

Albuminuria and Bright's Disease. By Nestor 
TiRARD, M.D., F.R.C. p.. Physician to King's Col- 
lege, London. London : Smith, Elder & Company, 
1899. 

These sentences from the author's introductory chap- 
ter supply a very good key-note to the contents of the 
book: "One of the chief difficulties connected with the 
term, Bright's disease, is that it has been so readily 
caught up by the non-medical world, and that it appears 
to be regarded among the laity as synonymous with 
albuminuria. This is much to be regretted as it fre- 
quently causes needless alarm and depression, when at 
some casual examination the presence of albumin in the 
urine has been detected." 

The author might well have said that something of this 
same misapprehension still clings to medical minds, too. 
His book is eminently well planned to do away with this 
false impression for it is a thoroughly scientific and up- 
to date discussion of albuminuria and its causes apart 
from Bright's disease, as well as of the various forms and 
phases of nephritis. 

The chapter on renal or true albuminuria without def- 
inite structural change is especially complete. The dis- 
cussion of the albuminuria that occurs after muscular ex- 
ercise, of the albuminuria of hematogenous origin which 
has been noted in anemic states, especially in severe 
chlorosis, and of neurotic and febrile albuminuria, shows 
that the author h. is most conscientiously consulted the au- 
thorities on the subject and gleaned from the copious liter- 
ature of nephritic and urinary conditions whatever is of in- 
terest and importance. The treatment of the subject of 
albuminuria seems especially to be commended inasmuch 
as a good deal of weight is laid on the opinion that phys- 
iological albuminuria is extremely rare, and that it should 
only be diagnosed when absolutely every possible patho- 



logical condition of the kidneys can be excluded. Dr. 
Tirard thinks it better to be over-cautious than to lull the 
patients into a false sense of security by the diagnosis of 
physiological albuminuria, albuminuria of adolescence and 
the like. Many of these subjects later develop true 
nephritis. 

In the chapters on nephritis are found excellent reviews 
of recent opinions with regard to congestion of the kid- 
ney, to uremia, with a complete discussion of late sugges- 
tions as to its etiology, and also the interesting question 
of the association of albuminuria and glycosuria which 
has been noted so often by recent observers, especially 
in severe cases of diabetes. The accompanying albu- 
minuria makes the prognosis of these cases even worse 
than when severe diabetes alone exists. 

Les Rayons de Roentgen et le Diagnostic de la 
TUBERCULOSE. Par A. Beclere, Medicin de I'Hop- 
ital Saint Antoine. Paris: J. B. Bailliere et Fils, 1899. 
Half of this work is devoted to a historical sketch of 
the subject of X-rays with a comparison of the merits of 
radioscopy and radiography. The author believes the 
former superior for the study of intrathoracic lesions in 
which the finer distinctions of shadows are lost in skia- 
graphs. For a subject yet in its infancy the author takes 
a most optimistic view of the efficiency of the X-rays in 
disclosing incipient tubercular affections of the lung. The 
nine skiagrams included are illustrative of the supposed 
value of skiascopy. 

Essays for Students. By Stephen Paget, 
F.R.C.S., Surgeon to the West London Hospital ; Sur- 
geon to the Ear and Throat Department of the Middle- 
sex Hospital. New York: Wm. Wood & Co., 1899. 
In a charming colloquial fashion the author has re- 
corded for students actual experiences on commonplace 
topics : strangulated hernia, cancer of the breast, some 
-run-over cases, and elements of aural surgery. By the 
perusal of these essays the student will learn how to elicit 
the unbiased history of any case. These notes are free 
from any coloring or verbosity ; yet the subjects are crit- 
ically treated, and the same thoughtfulness is applied to 
the operative advice which is thoroughly abreast of pro- 
gressive surgery. We hope that the success of this vol- 
ume will impel its author to venture on another on the 
same lines. 

Les Regenerations d'Organes. Par le Dr. Paul 
Carnot, Docteur des Sciences, Ancien Interne des 
Hopitaux de Paris. Pans: J. B, Bailliere et Fils, 
1899. 

This small compendium is a compilation of data bear- 
ing on the powers of regeneration in lower and higher 
animal life. In the first chapter regeneration is handled 
from the physiological, pathological, and traumatic stand- 
points, and these facts elucidated by comparison with zoo- 
logical and emoryological phenomena together with the 
biomechanical forces at play in influencing ontogeny and 
phylogeny. Under the heading, "Regeneration of Struc- 
tures Derived from Mesodermic Layer and Epidermic 
Layer," the practical feature of the regeneration of the in- 



96 



THERAPEUTIC HINTS. 



[Medical News 



dividual organs is discussed. The author concludes that 
for vertebrates and man regeneration of function is of 
paramount importance to form; /.<■., that the conserva- 
tion of function exacts the conservation of form which in 
many organs is assured by a diffuse hyperplasia of the 
entire organ in lieu of a local regeneration. 

S.^uxDERs' Medical Haxd-Atlases. Atlas of Di- 
seases OF THE Skin, Including an Epitome of Pathol- 
og)' and Treatment. By Professor Dr. Franz 
Mfacek of Vienna. Authorized Translation. • Edited 
by Henry W. Stehvagon, M.D., Clinical Professor of 
Dermatology in Jefferson Medical College, Philadelphia. 
With 63 colored plates and 39 full-page half-tone 
illustrations. Philadelphia: W. B. Saunders, 1899. 
The majority of medical schools in this countrj' give 
but slight prominence in their curricula to the study 
of skin diseases, and as a result many general 
practitioners experience no little difficulty in formulating 
a correct diagnosis and instituting proper treatment in 
these conditions. Elaborate treatises have appeared from 
time to time but comparatively few have fulfiled the re- 
quirements of any save specialists in this particular branch 
of work. 

No such criticism can be brought forward against the 
book under discussion. The first 191 pages are devoted 
to descriptions of the various skin lesions and their treat- 
ment, and the balance of the book to 104 full-page col- 
ored plates and haif-tone cuts. Each illustration is drawn 
from life, and is accompanied by a clear and concise his- 
tory of the disease in the patient whose case is pictured. 
A cross reference between the te.xt and an illustration and 
history referring to the same disease at once simplifies the 
matter of diagnosis and clearly defines methods of treat- 
ment and the results which may be expected. 

The translator's work has been well done and the edi- 
tor's bracketed comments, while not numerous, assist in 
the elucidation of the text. The colored plates are mas- 
terpieces in their way, and the book-making in its entirety 
reflects great credit on the publisher. 

Saunders" Medical Hand-Atlases. Atlas of 
THE External Diseases of the Eye, Including a 
Brief Treatise on the Pathology and Treatment. By 
Professor Dr. O. Haab of Zurich. Authorized 
Translation from the German. Edited by G. E. de 
. SCHWEixiTZ, M.D. With 76 colored plates and 6 
engravings. Philadelphia: W. B. Saunders, 1899. 
This is the American edition of Lehman's well-known 
series of hand adases, and this number, on the External 
Diseases of the Eye, has been highly praised as a very 
practical presentation of the subject for the general prac- 
titioner rather than the specialist. The colored plates 
are very well done, and reproduce the pathological condi- 
tions with great accuracy as regards color and relations. 
The translation has been well done, and the practical 
touch of the experienced editor's hand can be noted in 
places, making the German text more suited to .'Amer- 
ican practice. For stye, for instance, the German text 
writer suggests active poulticing with linseed meal to al- 
leviate suffering, and shorten the process by bringing the 



abscess to the point of spontaneous evacuation or inci- 
sion. The American editor suggests that repeatedly ap- 
plied compresses soaked in hot carbolized solution, or in 
hot water containing thirtj'-three per cent, of fluid extract 
of hamamelis, is preferable. Then the remark: "The 
conjunctival hyperemia induced by eye-strain is a con- 
stant cause of chalazia and hordeola, therefore the ne- 
cessity for correcting the refraction of the eye if it is 
anomalous," is just the added touch necessary to com- 
plete the clinical consideration of this ver)' practical sub- 
ject, but one which a German ophthalmologist would 
be apt to neglect. 



THERAPEUTIC HINTS. 



A Combination of Ichthyol and Creosote. — The good ef- 
fects obtained from the administration of each of these 
drugs in tubercular pulmonary affections decided Hugo 
Goldman to use them in combination. He prescribes 
as follows, claiming excellent results: 

B Creasoti \ ^ 

Ichthyol s^ ■ ■ ■ ■ 2SS 

Glycenni ..... 3 i 

Aq. menth. piper. ... 3 iiss. 

M. Sig. Twenty to 30 drops in wine or lemon- 
ade three times a day after meals. For children and 
weakly individuals the dose is 10 to 20 drops. 

For Squamous Blepharitis. — This occurs frequently in 
connection with seborrhea of the scalp, and gives rise to 
small crusts at the ciliary border of the eyelid. A 
sulphur ointment serves as the most effective means of 
cure, but is apt to cause a burning sensation and lachri- 
mation by entering the conjunctival sac. Terrien ad- 
vises, therefore, a weak preparation such as the following : 

5 Sulphuris praecip. . . . gr. iii 

Vaselini pur. . . . 3 v. 

M. Ft. unguentum. Sig. External use. 



Solution for Fetidity of the Mouth. — 

5 Camphoras 

Ac. salicylic! ) 
„■ ■ ■' V aa 

01. anisi \ 

Pulv. benzoini ) 

Calcis chlorate \ 

Glycerini . . . . . 3 vi 

Spiriti (forty per cent.) . . 3 x. 

M. Sig. Mouth wash. Keep in dark bottle. One 
teaspoonful in a glass of water. 



gr. l.x.xx 
3 iiss 

3 V 



For Fayus. — 



.51 
5SS 

? iss 



5 Potassii carbonat. .... 

Sulphuris sublim. .... 

Tinct. lodi [ 

Picis liq. \ ■ • • • _ 

Adipis ...... 3 iii. 

M. Ft. unguentum. Sig. External use. 

A thin layer of the ointment is spread on gauze and 
applied to diseased areas, being renewed daily. The 
slight dermatitis which may result is overcome by Lassar 
paste. — Pirogoff. 



THE MEDICAL NEWS 

A WEEKLY JOURNAL OF MEDICAL SCIENCE. 



Vol. LXXV. 



New York, Saturday, July 22, 1899. 



No. 



ORIGINAL ARTICLES. 



THE SERUM -T R E ATM EN T AND ITS RE- 
SUL TS . ' 

By HERMANN M. BIGGS, M.D., 

OF NEW YORK. 

Among the remarkable developments in medicine 
during the last ten years none has been more im- 
portant in its practical value, nor more revolutionary 
in its effect on therapeutic possibilities and concep- 
tions than the discoveries in serum-therapy. These 
discoveries have aroused the hope of the ultimate 
possibility of the production of artificial immunity to 
each one of the general infectious diseases of ani- 
mals and man by the administration of innocuous or 
almost innocuous substances of bacterial origin, and 
there has apparently been placed almost within our 
grasp means for the specific treatment of many of 
these diseases. 

The hopes earlier aroused in the minds of a few of 
the most enthusiastic workers in bacteriology have 
been more than realized in respect to diphtheria, 
and their most extravagant predictions have been 
actually exceeded by the results. The control of 
this disease, one of the most dreaded and fatal of 
diseases in modern times, has been rendered easily 
possible. The problems concerning diphtheria 
alone, however, of all the numerous and complex 
ones presented in bacteriologic therapy, have been 
completely solved so far as the practical aspects are 
concerned; but important contributions have been 
made to the solution of many others. In the study 
of each of these infectious diseases there are many 
unknown and variable factors whose determination 
requires most patient and painstaking investigation 
by methods newly worked out along new lines. 

A full consideration of the present status of the 
serum-treatment involves the study of a large num- 
ber of diseases, including diphtheria, typhoid fever, 
tetanus, pneumonia, streptococcus infections, chol- 
era, yellow fever, tuberculosis, plague, leprosy, 
snake-venom, rinderpest, anthrax, rabies, and several 
other diseases of animals. The mere mention of 
this list shows the far-reaching effect of the epoch- 
making discoveries in relation to diphtheria and 
tetanus. Satisfactory practical results have not thus 
far been obtained in most of these diseases, but 
something has been accomplished experimentally in 

' Read before the New York Academy of Medicine, March, 1899. 



all, and the scientific observations have definite 
value as they assist in the solution of other prob- 
lems. 

It was my privilege to present before the Academy 
in April, 1895, a paper on the antitoxin treatment 
of diphtheria, then in its infancy, and the results 
obtained from its then limited use by the Depart- 
ment of Health of New York City. That paper 
called forth violent opposition. At that time the 
supporters of and believers in the treatment were few 
in number. The majority of the profession were 
waiting for more information and more evidence. 
The past four years have supplied this in amount and 
character sufficiently convincing to compel the ac- 
quiescence of every intelligence, whatever may have 
been the previous prejudice. 

I desire first to consider rather carefully the re- 
sults obtained in the serum-treatment of diphtheria, 
primarily in this city, and then, briefly, the results 
in some other great cities of the world. 

A report of the results of the treatment of diph- 
theria with antitoxic serum (not including the hos- 
pitals) under the supervision of the Department of 
Health of New York City, covering the period from 
its inauguration, January i, 1895, to October i, 
1896, was published in the Medic.\l News in the 
issues for December 12, 19, and 26, 1896. The 
present report is intended to complete the data up to 
January 1, 1899. A summary of the cases previ- 
ously recorded is also included. 

It may be said in an explanatory way that on 
January i, 1895, the Department of Health of New 
York City commenced the use of diphtheria anti- 
toxin prepared in its bacteriologic laboratories. The 
supply of foreign preparations at this time was lim- 
ited; only a few vials of reliable antitoxin of any 
grade could be obtained (none was then being pro- 
duced in this country) and the prices were exorbi- 
tant, averaging about 80 cents per 100 antitoxin 
units (Behring's standard), or from $8 to Si 2 for a 
dose of from one-third to one-half the size of that 
now generally employed. All of the preparations of 
serum then in use were of a low grade, and their 
use has long since been entirely discontinued in this 
city. 

The serum originally prepared in the laboratories 
of the Department of Health was first employed in 
the hospitals, but as soon as a suflScient quantity was 
at hand, arrangements were made for its adminis- 



THE SERUM-TREATMENT AND ITS RESULTS. 



[Medical News 



tration without charge (at the request of the attend- 
ing physician) by inspectors detailed for this pur- 
pose to any case of diphtheria occurring in the 
city, and a little later arrangements were made for 
the free distribution of antitoxin to all public insti- 
tutions and for use among those too poor to pay for 
the remedy; and, finally, by a special act of the 
Legislature, the department was authorized to sell 
any surplus product, the proceeds from these sales 
to be deposited with the Comptroller as a special 
antitoxin fund, subject to requisition by the De- 
partment of Health for the further production of 
diphtheria antitoxin, or other antitoxins, and for 
the expenses connected with the treatment of cases 
of diphtheria among the poor. 

During the first period, ending October i, 1S96, 
1252 cases of true diphtheria were treated by the in- 
spectors detailed for this purpose, with 198 deaths, 
giving a mortality of 15.8 per cent. Of these 80 
were moribund at the time of the first injection, or 
died within twenty-four hours after the first injec- 
tion of antitoxin; deducting these, the mortality 
was 10 percent. From October i, 1896, to Jan- 
uary I, 1898, 1 1 95 cases were treated, with 163 
deaths, giving a mortality of i_t,.6 jier cent. Of 
these 71 were moribund; deducting these, the mor- 
tality in the second series was 8.1 per cent. From 
January i, 1898, to January t, 1899, there were 
treated 626 cases, with 68 deaths, giving a mortal- 
ity of 10.8 per cent.; deducting 21 moribund cases, 
the mortality was 7.7 per cent. During the whole 
period from January i, 1895, to January i, 1899, 
there have been treated in all 3073 cases, with 429 
deaths, giving an average mortality of 13.9 per 
cent.; deducting 172 moribund cases, there remains 
a total of 2901 cases, with 257 deaths, a mortality 
of 8.8 per cent. In addition to these 455 cases 
were treated and have been excluded from the table, 
either because they showed on bacteriological ex- 
amination no Loffler bacilli, and were not regarded 
as cases of true diphtheria, or were found to be 
cases of true diphtheria, and were transferred to the 
Willard Parker Hospital, and therefore passed from 
observation of the inspectors. 

The cases referred to do not include any of those 
treated in the various institutions of the city or in 
the hospitals of the Department, and were, as a 
rule, among the very poorest classes in the tene- 
ment-house districts. They have, generally speak- 
ing, been under the most unfavorable conditions; 
have been severe cases, or regarded by the physi- 
cians in attendance as hopeless cases, and have often 
come under observation late in the course of the 
disease. In a large proportion of the whole number 
there was practically no other treatment besides the 



administration of antitoxin. In some cases, 
strychnin, whisky, and other remedies were also 
given, but in many instances the physicians in at- 
tendance discontinued their visits after referring the 
cases to the Department of Health for the adminis- 
tration of antitoxin, as the families of the patients 
were too poor to pay for their attendance. 

There has been from the beginning a continuous 
and marked improvement in the results obtained, in 
consequence, it is believed, of the increased experi- 
ence in the use of this agent by the medical inspec- 
tors appointed to this duty, the earlier application 
of the treatment, the constant improvement in the 
character of the serum, and the larger dosage em- 
ployed. During the first year the mortality among 
these cases was 17.9 per cent., and during the last 
twelve months it was 10.8 per cent., moribund 
cases included. 

For the execution of the plan adopted for the 
free administration of antitoxin among the poor the 
city was divided into districts, each district being 
placed in charge of a medical inspector, who is al- 
ways on duty and liable to be called at any hour 
during the day or night. Requests for the adminis- 
tration of antitoxin are received at the office of the 
Department of Health from the attending physi- 
cian, and immediately referred by police telegram 
or by telephone to the inspector in charge of the 
district in which the case occurs. 

In a large majority of all cases treated only one 
injection of antitoxin was administered; in all se- 
vere cases since the end of the first year of the work 
the initial dose was large, varying from 2000 to 
4000 units, experience showing that the best results 
were obtained from large initial doses, and the ten- 
dency has been to constantly increase the size of this 
dose. This experience is in direct confirmation of 
the conclusions reached in the experimental investi- 
gations on animals. As a rule, the patients were 
seen a second time at the end of 24 hours, and 
when it was considered necessary a second injection 
was then administered. They were afterward seen 
at intervals as seemed necessary, until the disease had 
terminated either in complete convalescence or 
death. 

The serum employed has been generally of high 
grade, varying from 300 to 800 or more units in 
each c.c. Better results have been obtained with 
the use of high-grade preparations and with larger 
doses of antitoxin. In the earlier months, when 
large quantities of serum were administered, — the 
serum containing proportionately less antitoxin, — 
rashes were of frequent occurrence, and tneir fre- 
quency varied with different preparations obtained 
from different animals; but no reliable data as to the 



JOLV 22, 1899] 



THE SERUM-TREATMENT AND ITS RESULTS. 



99 



percentage of cases in which they appeared are at 
command. There has been a marked diminu- 
tion in the frequency with which rashes have oc- 
curred and in their severity since the use of the 
higher grade preparations, in which smaller doses of 
serum are employed. No case has come under ob- 
servation in which any permanent injury could be 
properly attributed to the remedy. 

The data as regards complications are incomplete, 
as in the class of patients treated — often the most 
ignorant of the foreign -born population under 
the conditions existing in the poorest tenement- 
houses — careful observations could not be made. In 
many instances, serious complications independent 
of diphtheria, such as scarlet fever, measles, and 
whooping-cough, acted as contributing or determin- 
ing causes of death in the fatal cases — all such have 
been included. In all, with few exceptions, in which 
the clinical features were unmistakable, the clinical 
diagnosis was confirmed by bacteriological exami- 
nation. In a few instances the result of the bacterio- 
logical examination was indecisive, while the case 
was evidently diphtheria, and these have been in- 
cluded. In others, bacteriological examinations 
showed clearly that the cases were false diphtheria, 
and all such have been excluded from the list. The 
usual practice has been, when a case was seen for 
the first time by the inspector (at the request of the 
attending physician), to administer an injection of 
antitoxin, if the disease seemed clinically to be diph- 
theria, and at the same time to make a culture from 
the throat for bacteriological examination, ifacul. 
ture had not been previously made. The course 
subsequently pursued in each instance depended 
upon the results of the bacteriological examination. 

When cases of diphtheria were seen in families in 
which there were other children, who had been ex- 
posed to the disease and when the parents would allow 
it, an immunizing injection was administered to each 
of the children and often to the adult members of the 
family. In most instances, recently, after immuniz- 
ing injections have been administered, no attempt 
has been made to separate the case of diphtheria 
from the well members of the family, as experience 
showed that such separation was unnecessary. Al- 
together 5108 persons in tenement-houses have been 
immunized, from 200 to Soo antitoxin units being 
administered to each person. These persons were 
members of nearly 2000 different families, and 
among them there occurred within 24 hours 26 
cases of diphtheria, of which one onl)' — a patient with 
croup — died. Undoubtedly in these persons, the 
disease was already developing at the time of the ad- 
ministration of the antitoxin, and the amount ad- 
ministered — an immunizing dose — was not sufficient 



to completely check the disease. After 24 hours, and 
within 30 days, 23 cases occurred. All of these patients 
recovered with the exception of i , who developed 
scarlatina and diphtheria on the second day after the 
immunization. This child died. After 30 days, so 
far as is known, 7 cases occurred, of whom two died, 
one on the 36th, and one on the 55th day, respect- 
ively, after the administration of the immunizing 
dose. In other words, in 5108 persons immunized 
in about 2000 families 4 deaths subsequently oc- 
curred — one from croup, which developed within 
24 hours; one from scarlatina and diphtheria, which 
developed on the second day, and 2 from diph- 
theria, which developed, i on the 36th, and the 
other on the 55 th day of the disease. The data re- 
garding the occurrence of cases of diphtheria among 
those immunized after 30 days are probably not 
complete, as many of these cases were not subse- 
quently followed. 

The experience of the inspectors with immuniza- 
tion is quite in accord with that obtained from the 
immunization of children in various institutions in 
this city and elsewhere, and indicates that the pro- 
tective influence of the immunizing injections can 
generally be depended upon to last from three to 
four weeks, although in many cases the period is ap- 
parently longer. The results have been better since 
somewhat larger doses have been administered. 
With the high-grade preparations of antitoxin now 
employed the amount of serum required for an im- 
munizing injection is so small — varying from 5 to 
15 minims according to the age oi the patient and 
the strength of the preparation — as to be entirely 
unobjectionable. In the earlier work, when young 
and feeble infants were immunized, some restless- 
ness, accompanied by more or less pyrexia, oc- 
curred in many cases during the first twenty-four 
hours, and not infrequently a rash appeared later. 

The accompanying tables, I., II., III., IV., and 
v., give more complete data concerning the cases 
of diphtheria treated with antitoxin by the Depart- 
ment of Health Inspectors, January i, 1895, to 
January i, 1899. 

I have also prepared a table showing the absolute 
number of deaths annually and the death-rates per 
100,000 population from diphtheria and croup in 
several of the large cities of the world, notably, 
Paris, Berlin, and New York, where diphtheria an- 
titoxic serum has been generally employed, which 
gives most striking testimony of the value of this 
remedy. In each of these great cities the death- 
rate has been reduced to less than one-half of the 
lowest death-rate recorded previous to 1894. In 
Paris the rate is about 30 per cent., and in New 
York about 29 per cent, of the rate for 1S94. In 



THE SERUM-TREATMENT AND ITS RESULTS. 



[Medical News 



1894 there were 2870 deaths from diphtheria and 
croup in New York City; pneumonia and tubercu- 
losis only exceeding diphtheria and croup in the 
number of deaths caused. In 1898 the deaths were 
923; the number of cases of diphtheria and croup 
reported in 1898 is also below the number for any 
year since 1893, and the case fatality is lower, be- 
ing 12.2 per cent., as contrasted with 40 per cent, 
for 1892, 36.4 for 1893, and 29.7 for 1894. The 
diminution in the actual number of deaths and the 
diminution in the death-rate per 100,000 popula- 
tion since 1894 has been greater in New York City 
than in any other great city in the world. 

These data are in striking contrast with the con- 
ditions in London, where diphtheria antitoxic 
serum has been used to a very limited extent outside 
of the hospitals of the Metropolitan Asylums Board. 
While there has been some reduction in the number 
of deaths from diphtheria in London since 1893, it 
is inconsiderable. The present mortality is still 
greater than that in London previous to 1894, and 
is in great contrast with the reductions which have 
taken place in other great cities. Previous to 1894 
there had been a very great increase in London in 
the notifications of diphtheria and croup and the 
deaths from these diseases. In 1S93 there were the 
greatest number of deaths ever recorded — 34^4- 
Cobbett in a recent article has carefully analyzed 
the conditions, and has ascribed the difference in 
the results obtained with reference to this disease in 
London and on the Continent to several causes: 
ist, the increasing prevalence of the disease in Lon- 
don in recent years; 2d, the severe type prevailing; 
3d, the poor quality of the serum; 4th, the much 
less extensive use of the serum. 

Dr. Goodall, however, commenting on the sta- 
tistics given by Cobbett and the results of his calcu- 
lations, gives the following table showing the per- 
centage mortality of all cases of diphtheria in 
London City and in the Metropolitan Asylums 
Board hospitals since 1892: 



Fatality per cent, of all 
notified cases 

Fatality per cent, of all 
notified cases admit- 
ted to M. A. B. Hos- 
pitals - - - 

Fatality per cent, of all 
notified cases not ad' 
mitted to M. A. B 
Hospitals 

Percentage of notified 
cases admitted to M. 
A. B. Hospitals 



IS92 


■893 


23-S 


24-5 


24. S 


27.1 


21.5 


23-7 


3I-I 


24.5 



24.7 21.2 
25.5 1 18.3 

24-5 j 23.3 
38-8 41-5 



19.4 
'7-7 

21-3 

39-9 



■7-4 



14.9 



S«.4 



"This table," Goodall remarks, "shows, but 
more emphatically than Cobbett's tables, that 



whereas the fatality of hospital-treated cases was up 
to 1894 greater than that for the whole of London, 
since that year the reverse has been the case. It 
also shows that the improvement in the fatality-rate 
is more marked in the hospital cases than in those 
not admitted to hospitals. It further shows that 
there has been some improvement in the fatality of 
cases not admitted to hospital. It is very uncer- 
tain that the improvement in these last cases is due 
to the use of antitoxin. Doubtless some cases are 
admitted to the general hospitals and are treated in 
them with serum. Possibly the improvement may 
be due to this fact; but, if so, it only emphasizes 
Cobbett's statement, to the effect that outside of 
hospitals the antitoxin treatment is little employed." 
Goodall says that from his own experience he knows 
this to be the case. 

A reference should also be made to the remarka- 
ble results which have attended the use of diphtheria 
antitoxic serum in Chicago under the supervision of 
the Department of Health. During the month of 
November, 1898, according to the reports of the 
Department of Health for December, 1898, 168 
cases of diphtheria were reported to the Department 
and examined bacteriologically. Of these g8, found 
to be true diphtheria, were treated with antitoxin. 
Four cases remaining over from the preceding month 
were also under treatment. Of the 102 cases 97 are 
reported as having recovered, 2 remained under 
treatment, and 3 died, giving a mortality of three 
per cent, in completed cases. Ten of the patients 
treated were intubated, so that diphtheria during 
the month was not of a mild form. Two of the 
3 deaths were intubation cases, and all 3 of the fatal 
cases were first seen by the inspectors of the De- 
partment later than the fourth day. To this report 
for the month are appended the following details of 
the results obtained in Chicago since the original in- 
troduction of the antitoxin treatment by the De- 
partment in October, 1895: During the succeeding 
twenty-six months to date, the physicians of the De- 
partment have examined 5739 cases of suspected 
diphtheria. Of these 3956 were found to be true 
and all but 134 (treated by family physicians) were 
treated by the Department. Out of the 3822 cases 
thus treated 3763 recovered and 259 died, a mor- 
tality of 6.7 per cent. Before the introduction of 
antitoxin the mortality-rate of diphtheria in Chicago 
was thirty-five per cent. ".\l this rate there would 
have been 1337 deaths among the number actually 
attacked instead of 259 — a clear gain of 1 100 lives 
in a space of scarcely more than two years. Besides 
this there were 3633 persons immunized in families 
exposed to infection. Only 30 out of this number 
were subsequently attacked by the disease; they all 



July 22, 1899] 



THE SERUM-TREATMENT AND ITS RESULTS. 



had mild attacks and recovered. " It is estimated 
by the Chicago Board of Health that in twenty-six 
months there has been a saving to the City of Chi- 
cago, thanks to diphtheria antitoxin, of 1713 lives. 

A consideration of the deaths and the mortality 
per cent, in the hospitals of Paris, Berlin, and Lon- 
don shows the same facts as the rates for the entire 
cities, the number of deaths and n-.ortality percent, 
in Paris and Berlin having been reduced to a third 
or less, while in London the reduction has been far 
less and the number of cases treated has nearly 
doubled. 

The large reduction in the number of cases of 
diphtheria in New York in the last year as compared 
with the six years immediately preceding I believe 
to be due to several factors: First, the general use 
of antitoxin and the consequent diminished severity 
of the cases occurring. A severe case of diphtheria 
is far more likely to be a source of infection to 
others than a mild one, especially in the tenement- 
house districts, because the discharges from severe 
cases are so much more abundant, and the difficulty 
in destroying them is so much greater. Second, the 
use of antitoxin as an immunizing agent has largely 
decreased the number of secondary cases. Nearly 
2000 persons, mostly children (who had been ex- 
posed to diphtheria), were immunized during the 
last year by the Department of Health, and the rem- 
edy has also been largely used for this purpose by 
private physicians. Third, the introduction by the 
Department of Health of the medical inspection 
of schools, and the greater care in the inspection of 
cases in leneraent-house districts have both contrib- 
uted to the result. 

But not only has there been a great decrease in 
the deaths in the great cities, but the same has been 
found to be true in the smaller cities of France and 
Germany, where this subject has been carefully in- 
vestigated. In 266 German towns, with a popula- 
tion of over 15,000, for nine years preceding 1895 
the average deaths per 10,000 inhabitants was 106. 
In 1S95 this fell to 53, in 1896 to 43, and in 1897 
to 35, or less than one-third of the average for nine 
years previous to 1894. 

Sidney Martin of London, in concluding a careful 
report on the results obtained from the use of anti- 
toxic serum in the University College Hospital, Lon- 
don, in which the death-rate is shown to have dimin- 
ished from 37 and 39 percent., respectively, 'in 1S93 
and 1 894 to 17 percent, in 189 7, and the death-rate in 
operative laryngeal cases from 65 per cent, to 26 per 
cent., says "the great reduction, both in the total 
and in the tracheotomy mortality can only be due to 
the treatment with antitoxic serum, for the examin- 
ation of the cases revealed no other factor capable of 



producing this result. ' ' Martin recommends the use 
of very large initial doses, not less than 6000 normal 
units, and insists that it should be administered as 
soon as a suspicious throat is seen, without waiting for 
a bacteriological diagnosis of the disease. He also 
gives a table to show the diminished severity of the 
disease, and the shorter duration of the pyrexia when 
antitoxin is employed. 

The conclusions of the Committee of the .American 
Pediatric Society in reporting an investigation of the 
antitoxin treatment of laryngeal diphtheria in private 
practice need only be referred to. i 704 cases of 
laryngeal diphtheria were included in this report as 
treated w-ith antitoxin, of which 668 were operated 
upon. Of these 182 died, giving a mortality of 27.2 
per cent. Before the use of antitoxin it was es- 
timated that 90 per cent, of the cases of laryngeal 
diphtheria required operation, whereas now only 39 
per cent, require it. Previously 27 per cent, ap- 
proximately represented the recoveries, while now 
27 per cent, represents the mortality, exactly re- 
versing the figures; in other woids, before the use 
of antitoxin 27 per cent, recovered, while now 73 
per cent, recover. 

I desire to say a few words further in regard to 
the use of diphtheria antitoxic serum for immuniza- 
tion against diphtheria, for while the remedy is now 
universally employed throughout the world in the 
treatment of this disease it is much less generally em- 
ployed as an immunizing agent. It was early employed 
in New York City, and has been more generally used 
here for this purpose than anywhere else in the world. 
The results here, however, have had ample confirma- 
tion in Europe. In the children's department of the 
Charitc Hospital, Berlin, where formerly patients fre- 
quently contracted the disease, owing to the want 
of efficient isolation, the systematic use of immuniz- 
ing injections was introduced three years ago. 
Since January, 1896, patients have even received 
injections every three weeks, as it was found that the 
resulting immunity could not be depended upon for 
a much longer period than this. The result has been 
that no child thus immunized has contracted the dis- 
ease; this fact seems more remarkable because it was 
found that the diphtheria bacilli were present in the 
throats of nearly one-quarter of the children who 
were examined during a period of 5 months. 

In order to ascertain whether the resulting immu- 
nity was due to the injections, or to some other in- 
fluence, the injections were stopped in October, 
1897. Shortly afterward, namely, early in Novem- 
ber, a child three and a half years of age, suffering 
from Bright's disease, developed laryngeal diph- 
theria and died. A little later two other chil- 
dren in the same ward were attacked with typical 



THE SERUM-TREATMENT AND ITS RESULTS. 



[Medical News 



pharyngeal diphtheria, and a fourth child, who had 
been admitted for measles early in October, de- 
veloped croup. These last three patients recovered 
after the injection of diphtheria antitoxin. After 
this experience the immunizing injections were re- 
sumed, and no further cases of diphtheria have oc- 
curred. The experiences previously reported in in- 
stitutions in this city give exactly parallel results. 

I shall only refer the reader to the accompanying 
tables for the results in the laryngeal cases treated by 
the inspectors of this city, although in many re- 
spects these afford the best test of the efficacy of 
the antitoxin treatment. 

From the statistics presented it is apparent that 
the mortality from diphtheria and croup, which was 
so markedly reduced on the introduction and in con- 
sequence of the use of antitoxin, has continued to 

Table. I. 

Cases of diphtheria treated with antitoxin by the Department of 
Health. January i, 189S, to January 1, 1899, witli a summary of 
cases treated, January r. 1895, to January i, 1S99, 

Total cases of true diphtheria injected with antitoxin by the 
Medical Inspectors of the Department of Health, showing the 
number of cases injected and the mortality percentage. 





Cases. 

626 

21 

605 


Deaths. 


Mortality 
Per Cent. 


Jan. I, 1898, to Jan. 


1,1899.. 


68 
47 


10.8 






7-7 






Jaiy. I, 1895, to Oct. 


I, 1896.. 


J. 252 

So 

1,172 


198 
118 


■5.8 


Remaining 








Oct. I, 1896, to Jan. 
Moribund deducted. 


I, 1898.. 


1. 195 

71 

1,124 


■6j 
92 


>3-6 
81 








Total cases, Jan. i 

Jan. I, 1S99 

Moribund deducted. 


1895, to 


3.073 

172 

2,901 


429 

257 


'39 


Remaining 




8.8 



decrease in proportion as the remedy has been more 
generally employed. It would be useless at this 
time to multiply statistics on this subject, which on 
the largest scale, and Irom the most diverse sources 
have given affirmative evidence of the value of 
antitoxic serum in the treatment of diphtheria. 
It is not easy to understand the mental atti- 
tude of those who still continue to oppose the 
antitoxin treatment of diphtheria in the face of 
the enormous mass of evidence in its favor. What- 
ever may be said of statistics in general, no practi- 
tioner who examines impartially the reports pub- 
lished by the New York City Department of Health, 
and reads the wholly unprejudiced and impersonal 
collective investigations instituted by the American 
Pediatric Society, by the Berlin Society for Internal 
Medicine, and the Kaiserliches Gesundheitsamt, and 



the exhaustive and elaborate statistical studies is- 
sued by the medical superintendents of the hospitals 
of the London Asylums Board can fail to be con- 
vinced of the specific value of this remedy. 

Table II. 
Cases of laryngeal diphtheria treated witli antitoxin by the De- 
partment of Health, January i. 1898, to January i, 1S99, with 
summary of cases treated January i, 1895, to January i, 1899. 
Total cases of laryngeal diphtheria injected with antitoxin by the 
Medical Inspectors of the Department of Health, showing the 
number of cases injected, and the cases, deaths, and mortality per- 
centage in both operative and non-operative cases. 





Laryngeal 
Cases. 


Non-operative! 
Cases. 


Operative 

Cases 

(Intubation.) 




U 


1 






u 
125 

7 
118 

283 

34 

249 

214 
3' 
•73 

622 
72 

550 


14 


11.2 


ai 

01 

(d 

60 

4 

56 

72 

4 
68 

72 
'4 
58 

204 

22 
182 


U7 

Q 
18 


" 

a. 


Jan. I, 1898, to Jan. 
1, 1899 


185 

II 

'74 


32 


'7-3 


30.0 


Moribund deducted 




21 


12. 


7 

79 


7.0 

— 1 

27.9 


'4 

29 


25.0 




Jan. I, 1895, to Oct. 
I, 1S96 


355 

38 

317 


io8 


30,4 


40.2 


Moribund deducted. 




70 


22.4' 

27.2 


45 
51 


'7-9| 
23.8 


25 
27 


36.7 




Oct. I, 1896, to Jan. 
], 1S98 


286 

45 
241 


78 


37-4 


Moribund deducted. 


Remaining 


33 


'3.7 


20 
144 


ii.6| 
23- 1 


13 
74 


22.4 




Total Cases, Ian. i, 
1895. to Jan. I, 
1899 


826 

94 
732 


2l8 


26.4 


36.2 


Moribund deducted. 




124 


16.9 


72 


'3' 


52 


78 I 







Table III. 
Cases of diphlheria treated with antitoxin by the Department of 
Health, arranged according to age, January i, 1898, to January 1, 
1899, with summary of cases treated, January i, 1S95, to January 
I, 1899. 





1 

6 


2 


2 

I 

N 

120 
20 

16.6 


102 

9 

8.8 


2 

s 

x 

'81 

8 

9.8 


£ 

T " 

175 
'5 

8.6 



Z 2 

> V 

>■ 

35 

1 

2.8 


"(5 

H 

626 
68 

10.8 


■v-6 

.11 

21 

... 


2 ti 

as 


Jan. 1, 1898, to 

Jan. I, 1899. .. 

Cases 


23 

1 

4-3 


90 

'4 
'5-5 


605 
47 

7-7 


Deaths 


.Mortality 

per cent. 


Jan. I, 1895, to 

Oct. I, 18915... 

Cases 


74 

21 

28.3 


214 

51 

23-8 


252 

43 
17.0 


189 

30 

'5.9 


182 

26 

14.2 

16 
II. 8 

398 
50 

10. 


260 
26 

10. 

331 
33 

9.9 

766 
74 

9.6 


81 
1 

1.2 

91 
2 

2.2 

207 

4 
'.9 


1252 
.98 

15.8 

1 195 
•63 

13-6 

3073 
429 

13-9 


80 
7' 

172 


1172 

TlR 


Deaths 


Mortality 

per cent. 


10.0 


Oct. I, 1896, to 

Jan. I, 189S... 

Cases 


61 
13 

21.3 


184 
34 

18.4 

48S 
99 

20-3 


202 
42 

20.5 

574 
105 

.8.3 


191 
23 

12.0 

482 
62 

12.9 


1124 


Deaths 


92 
8.1 


Mortality 

per cent. 


Total Cases. 
Jan. I, 1895, to 

Jan. I, 1899. .. 
Cases 


158 
35 

22.1 


2901 
257 

S.8 


Deaths 


Mortality 

per cent. 



July 22, 1899] 



THE SERUM-TREATMENT AND ITS RESULTS. 



103 



Table IV. — Cases of diphtheria treated with antitoxin by the Department of Health, arranged according to day of disease on which 
treatment was begun, January i, 1898, to January 1, 1S99, with summary of cases, January i, 1895^ to January i, 1899. 







I St 


Day. 


2d 


Day. 


3d Day. 


4th Day. 


Sth Day 
or Later. 


Day 
Unknown. 


Total. 






tn 


g 


u 


1 

V 

a 


148 

4 
'11 


2 

S 

Q 


U 


to 

1 




•s 
•s 

u 


"5 
Q 






m 2 




Jan. 1, 1898, to Jan. i 
Mortality per cent 


1S99.. 


69 



69 



0.0 


0.0 


183 

2 
181 


8 

4-3 

' "e 
3.3 


21 

14.2 

n 


88 

4 
84 


13 
"4.7 

9 
10.7 


137 


26 
19.0 


I 



1 



0.0 


0.0 


626 

21 
605 


68 
10.8 

47 
7-7 


10. 8 


Remaining 


126 1^ 


7.7 


Mortality per cent 


.... 1 II. 8 




12.0 




Jan. I. 1S95, to Oct. I 
Mortality per cent. . , . 
Voribund deducted. . . 


1896.. 


157 

s 
152 


n 
7.0 

14 
4.0 


33^ 

14 
217 


30 
9.0 

"16 

S-4 


293 

17 
276 


42 
14.3 

25 
9.0 


197 

15 
1 82 


39 
20.0 

24 
13-2 


262 
25 


72 
27.4 


12 

4 
8 


4 
33-3 


0.0 


1.252 

"80 

1,17^ 


198 
15.8 

. lis 
10. 


IS.S 




237 47 
.... 20.0 


lO.O 


Mortality per cent 




Oct. I. 1896, to Jan. 1, 
Mortality per cent. . ., 
Moribund deducted . . . 


1898.. 


120 

I 

119 


2 
1.6 

I 
0.8 


253 

1 

252 


6 
2.3 

S 

1.9 


257 

5 
252 


si 

"is 
7-1 


198 

"16 

182 


14.6 
13 

7.t 


359 

"■46 
3^3 


lOI 

27.S 

55 
17-5 


8 

2 
6 


2 
25.0 


0.0 


1. 195 

71 
1,124 


163 
13-6 

.... 

92 
8.1 


13.6 




8.1 


Mortality per cent 




Total Cases. 
Jan. T. 1895, to Jan. i, 
Mortality per cent. . . . 
Moribund deducted... 


1898. . 


346 

"6 
340 


13 
3-7 

7 

2-5 


767 

17 

750 


44 
5.6 

27 
3-6 


698 

672 


86 
12.4 

"60 
8.9 


483 

448 


Si 
16.9 

■■46 
10.2 


758 

"82 
676 


199 
26.2 

"7 
17-3 


21 

3. 


6 
28.6 


0.0 


3.073 

172 
2.901 

.... 


429 
'3-9 

257 
8.8 


•3-9 




8.8 


Mortality per cent 





Table V. 

Immunization with antitoxin by the Department of Health In- 
spectors, January i. 1898, to January i, 1899, with summary of 
cases immunized, January i, 1895, to January i, 1899. 

Table of cases immunized with injections of antitoxin in families 
where diphtheria had occurred, showing the number of cases im- 
munized, the number of cases which occurred after thirty days 
and within twenty-four hours after injection, and those which oc- 
curred within thirty days after injection. 



Table V. — Continued. 



No. of Cases 
Immunized. 



No. of Cases of Diphtheria'^"; "^^asesof Diph- 
within 30 days after In-; "-^"'^ "'"*"° ^ 



jection. 



Jan. 1, 1S9S, to I on the 7th day, moderatelj 
Jan. 1, 1899. severe, recovered. 
1,408 Cases. I on the 3d day, mild, re- 
covered. 
I, no day stated, mild, re- 
I covered. 



1,207 Cases. 



Jan. 1, 1S95. to I on the 7th day, j 
Oct. I, 1896. I on the loth day, j ,,., , 

5 on the 19th day. l-*™;5^- 
I on the 23d day, covered. 
I on the 30th day, J 
I on the sth day, severe, re- 
covered. 
I scarlet fever and diphthe- 
ria, died on the 2nd day. 



Oct. I, 1896,102, no day stated,^, 
Jan. I, 1S9S. 2 on the 7th day, j .,-,, 
2,493 Cases. 2 on the Sth day, ;.»l"d,re- 
I on the 9th day, i ™vered. 
I on the 12th day, J 
I on the 30th day, moderate- 
ly severe, recovered. 



hours and after 30 
days after Injection. 



Jan, I, 1895, to 
Jan. i' 1899. 
5,108 Cases. 


19 mild, recovered. 
3 severe, recovered. 
I scarlet fever and diphthe- 
ria, died on the 2d day. 


Within 24 hours. 
15 mild, recovered. 
10 severe, recoverecl. 

1 croup, died. 

After 30 days. 

3 mild, recovered. 

4 severe, recovered. 

2 septic, died on 55th 
and 38th day, re- 
spectively. 



Note to Table V. : There were, in all, 1538 families in which 
one or more cases of diphtheria had occurred previous to immuni- 
zation. Out of a total of 5108 cases immunized during the four 
years, 1895 to 1899, only 3 deaths from diphtheria occurred, i de- 
veloping on the second day after immunization of scarlatina and 
diphtheria, and 2 septic cases on the fifty-fifth and thirty-eighth 
days, respectively, after immunization ; 25 cases of diphtheria which 
occurred within twenty-four hours, 22 cases within thirty days, and 
7 cases after thirty days after injection, in all 54 cases, recovered. 

On October i, 1895, arrangements were made to 
enable physicians to obtain supplies of antitoxin 
free for use among patients too poor to pay for the 
remedy, on condition that reports of the cases thus 
treated should be furnished to the Department of 
Health. Druggists acting as agents for the sale of 
antito.xin were instructed to furnish the remedy free 
to any physician upon his statement that the pa- 
tient for whom it was intended was not in circum- 
stances to pay for it. A blank was furnished upon 
which the history of the case could be filled out by 
the attending physician upon the termination of the 
case, either by death or recovery. This arrange- 



I04 



THE SERUM-TREATMENT AND ITS RESULTS. 



[Medical News 



merit, not very generally known or utilized by phy- 
sicians at first, has come more and more into use 
until now a large number of cases of diphtheria are 
treated by physicians with antitoxin furnished free 
to poor patients. 

T.4BLE VI. 

Cases of diphtheria treated by physicians with free antitoxin, 
collated from the reports of the attending physicians, January i, 
1898, to January i, 1899. with summary of cases treated, October 
I, 1S95, to January i, 1899. 



Mortality 
Per cent. 





Cases. 


Deaths. 


Jan. I. 1S98, to Jan. i, 

1899 

Moribund cases deducted. 
Remaining 


868 

60 

80S 


•38 
"78 


ToT.\L Cases. 
Oct. I, 1S9S, to Jan. I, 

•899- 

Moribund cases deducted. 
Remaining 


2,112 

»43 

1.969 


373 
230 



15-9 

"9.6 



■7.6 



Note TO Table VI.: From January i, 1S9S. to January i, 
1899, there were treated with free antitoxin 868 cases, with 13S 
deaths, giving a mortality of 15.9 per cent. ; of lhese6o were mori- 
bund at the time of or died within twenty-four hours after the 6rst 
injection: deducting these the mortality was 9.6 per cent. Of the 
total cases treated with free antito.xin from October i, 1895, to Jan- 
uary I, 18^, viz.. 2112, 373 died, giving a mortality for the three 
years of 17.6 per cent. Deducting 143 moribund cases the mortal- 
ity was II. 7 per cent. 

Altogether 2511 cases of suspected diphtheria were injected with 
free antitoxin, October i, 1895. to January i, 1899, but 399 of 
these are excluded from the statistics, either because on culture 
examination no diphtheria bacilli were found, or because they were 
transferred to the Willard Parker Hospital; and thus passed from 
observation, or because the data furnished were insufficient for 
tabulation. 

Of the 2112 cases included in the statistics, 1458 were bacterio- 
logically confirmed to be true diphtheria; of these iSo cases died, 
or 12.3 per cent. Of the654 cases not confirmed by bacteriological 
examination, but proving to be clinically undoubted diphtheria, 
173 died, or 26.5 per cent. Many of these were moribund at the 
time of the first injection. 

Table VII. 
Cases of laryngeal diphtheria treated by physicians with free 
antitoxin, January I, 1898,10 January i, 1899, with summary of 
cases, October i, 1895, to January i, 1899. 



Jan. I, 1S98, to Jan. 

I, '899 

Moribund deducted. . 
Remaining 



Total ., . „ . 

Larjngeal -^on^^P^ative Operauve 



Cas 



Cases. 



Cases. 



U 



S c 5 



292 8428.7 

40 I 

252. 44 i 17-4 



u 
205 

.1? 


Hi 

48 


2* — 

Is 

22.9 


u 

83 
12 

71 


20 


tl.O 



o 5 

SB, 



43-3 
33'8 



Total Cases. 
Oct. I, 1895, to Jan. I I 

1,18^ 748 I 227 !3 J 26.2:219 

Moribund deducted . . 98' '.... .j; 31 

Remaining 650 129 19.8I 462 I 72 1 15.61 18S 



40.2 



30.3 



Table VIII. 
Absolute annual deaths and death-rates for 100,000 population 
from diphtheria and croup in Paris, Berlin, and New York (Man- 
hattan and Bronx) from 18S6 to 189S inclusive. 





Paris. 


Berlin-. 


New York. 




ti . 


s 8 = 




^ 8 c 




S § c 














« c 




oS 


^%3. 


'0'^ 


1%-^ 


rf 


:8s 




1- 


Deal 
per 1 
popu 


^ n. 

<" 


Deal 
per I 
popu 


|c 


III 


1886 


1.524 


73-2 


1,662 


125-7 


2,695 


187. 5 


1887 


1,564 


76.9 


1.392 


100.7 


3.056 


206.6 


iSSS 


1,718 


83.7 


1,195 


76.1 


2,553 


167.7 


I8S9 


1,706 


79-9 


1,210 


85.6 


2.291 


146.2 


1890 


1.639 


77.5 


1,601 


102.0 


1,783 


no. 6 


I89I 


1.363 


63.0 


1,3*2 


67.5 


1,970 


118.7 


IS92 


1.398 


63.6 


•,637 


92-5 


2,106 


123.3 


1893 


1,262 


5I.4 


1,416 


100.8 


2,558 


145-5 


1894 


993 


40.7 


1,321 


86.7 


2,870 


158.4 


1895 


435 


17. s 


9S7 


59-2 


1.976 


105.2 


.S95 


444 


17.6 


559 


30.4 


1,763 


91.2 


IS97 


351 


"3-8 


546 


3>.5 


1,590 


79-9 


IS98 


30« 


12.0 


652 


32.4 


923 


45-1 



Note: The figures for 1S97 and the first half of 189S in Paris 
and Berlin are taken from the monthly reports, while the latter 
half of 1S9S is estimated from tlie weekly reports. The rest of the 
data are taken from the annual reports. 

It will be seen from an examination of this table that the average 
number of deaths from diphtheria and croup in Paris and Berlin 
for the preantitoxin period (1886 to 1895) was 1463 and 1419 re- 
spectively, whereas for the antitoxin period (1895 to 1899) it was 
383 and 656, or less than one-half. In New York City antitoxin 
has not been so generally used as in the other two cities until the 
last year. But the average number of deaths from diphtheria and 
croup in New York from 1886 to 1895 was 2654, while from 1S95 
to 1899 it fell to 1563. and in 1S9S it was only 923. The fall in the 
death-rate from this disease since the introduction of antitoxin is 
equally conspicuous, estimated per 100,000 of the population. 

Diphtheria has always been much more prevalent in the great 
cities of this country, and especially New York, than in the cap- 
itals of Europe, and the death-rate per 100,000 of the population 
has always been and still remains much higher. The diminution 
in the death-rate, however, in 1S9S, as compared with 1894, is 
greater in New York than in either Paris or Berlin, or any great 
city of Europe. The case fatality, too, isasloworlower than that of 
any oiher great city. The great prevalence of the disease in New 
York is no doubt due to the great density of the pMDpulation and 
the character of the housing of the tenement-house population, 
which is more favorable to the extension of infectious diseases 
than that of any great city of the world. 

Table IX. 
Diphtheria and croup in New York City from i8qi to iSgS in- 
clusive, showing cases, deaths, and case fatality. 







Cases. 




Deaths 


1 

i 


Case 
Fatalitv. 




i 






rt 




1 


.2 '.2e 






c 


_; 




^ 


_; 


5 Ig 














n 1 








c 





^ 








- 1 =u 




Cl. 


G 


f- 


C 


U 


H 


■5. 1 .2^ 




Q 






C 






1 


I89I 


4.874 


490 


.S„364 


1.361 


609 


1,970 


27.9 36.7 


1892 


4,654 


530 


5.184I 


1,436 


670 


2.196 , 


30.9 40.6 


1S93 


6,468 


553 


7,021 


1,970 


588 


2,558 


30-4 36-4 


IS94 


9,155 


486 


9.641 


1 2,359 


5" 


2,870 


25.S 


29-7 


1895 


9.925 


42S 


10,353 


, 1.634 


342 


1,976 


16.4 


19-1 


1896 


11,095 


.306 


11,399 


1,555 


20S 


1,763 


14.0 


15-4 


1897 


10,496 


400 


10,896 


1.376 


214 


1,590, 


13- 1 


14.6 


I89S 


7,2'3 


380 


7,593 


788 


135 


923 i 


10.9 


12.2 



jLl.V 22, 1899] 



CONSUMPTION IN COLORADO. 



105 



Note; Previous to 1891 croup, not being classed as a contagious 
disease, was not reported to the Health Department. In January, 
1895, the distribution and use of antitoxin produced by the New 
York Department ot" Health was begun, but antitoxin did not come 
into general use in the city until 1896. 

Table X. 
Cases, deaths, and mortality percentage of all cases of diph- 
theria in the hospitals of Paris, Berlin, and London from 1893 to 



'893 
1894 

1895 
1896 
1S97 



1 


=ARIS 




B 


ERLIN 




LO.NDON 




Ho 


■^[>1TA1. 




Hospital 




Hospitals. 


U 


ui 

J= 

n 
a 

a 


- c 

5 

so. 


«i 

u 


s 

Q 


.18.8 


m 

V 

u 


« 

M 




I.8S2 


96S 


51-4 


2,450 


951 


2,848 


S65 


30-3 


2.355 


837 


15-5 


2,S90 


Soi 


27.7 


3.666 


1.035 


28.2 


2,664 


^b^ 


'3-6 


3>o6t 


484 


.5.8 


3.685 


S20 


22.2 


2 -,56 J 


360 


'5-2 


2,i-)8 


28.S 


13-3 


4.S0S 


948 


21.0 


1,683 


253 


I5-0 


1.937 


263 


.3.5^ 


5,673 


987 


17-4 



Note; The statistics for 1898 have not been published in full, 
and are, therefore, omitted. Antitoxin was introduced into the 
hospitals of Paris and Berlin toward the end of 1S94, but was not 
generally employed until 1895. In the hospitals of ihe Metropol- 
itan Asylum Board of London antitoxin w^as not introduced until 

1.895- 

(To be coutiiiued.J 



LIGHT AND AIR IN THE TREATMENT OF 
CONSUMPTION IN COLORADO.' 

By CHARLES FOX GARDINER, M.D., 

OF COLORADO SPRINGS, COL. 

In the etiology of pulmonary tuberculosis one fact 
stands out more clearly and is proved more positively 
than any other, and that is the enormous influence 
such simple factors as light and fresh air have upon 
the development of this disease. In fact from the 
dawn of human history this influence has been noted/ 
and all human experience as well as scientific re- 
search have demonstrated that consumption is a dis- 
ease of the indoor domestic animal, man included, 
and that when air and light are curtailed, then con- 
sumption begins to strike down those who from de- 
ficient lung power are least fitted to survive. An- 
other fact now proved beyond question is that 
reversing the greatest predisposing cause (a lack of 
air and light), and supplying the air and light to ex- 
cess, we have the most powerful weapon now known 
with which to fight and conquer this widespread 
and destructive disease. Even nutrition, important 
and powerful as it certainly is in treating the tuber- 
cular, must hold second place to light and air. I 
have seen hundreds of range cattle exposed to air and 
light dying of starvation and cold and never a case 
of tuberculosis among them; while, on the other 
hand, cattle from the same herd, sheltered, well fed 

' Read at the sixteenth annual meeting of the American Clima- 
tological Association, held at New York, May 9, 10, and 11, 1899. 
' Aryteus Celus, "Treatment of Consumption." 



and cared for, do occasionally develop the disease. 
It seems to me that, in the face of such strong evi- 
dence as we can now show as to the value of air and 
light in curing consumption (a remedy far more ef- 
fectual than all other agents taken together), the 
average physician passes over them with scant no- 
tice, and the brief order to the patient, "Be out all 
you can," results in but a small daily dose of fresh 
air — a quantity entirely too limited for the result de- 
sired. That this is a mistake, and that the most ef- 
ficient remedy we have for consumption should be 
used with care, system, and in heroic doses, is very 
clearly shown by the results obtained in the sanato- 
riums both in this country and abroad. ' 

When used as a cure the qualities of the air should 
be considered; these depend upon climatic condi- 
tions, and to state, as some men have, that, condi- 
tions being equal in other 'espects, climate is 
of little importance is not true or logical. As the 
dose and purity of a drug determine its favorable ac- 
tion upon the diseased condition it is intended to 
cure, so the dose and purity of the air and light, 
used as a cure, determine their efficient action in 
consumption. Any student of climatology knows 
that air and light differ materially in available dose 
and purity, even in narrow geographical limits, while 
a more extended view shows us climatic changes 
much more intense and radical. Air ought to be 
(i) pure — free from dust and germs;' (2) dry and 
thin — to favor chest expansion, to give greater sup- 
ply of blood to the lungs and increased richness 
to the blood, and also to permit greater penetration 
of solar rays, thus limiting tubercular infec'.ion from 
others;' (3) cool — to act as a stimulant; (4) and 
with an excess of ozone and electricity.' 



' Otis,"Hospitalsand Sanatoria for Consumption Abroad," Bos- 
ton Med. and Surg. Jour., p. 22, 189S. 

5 Tuberculosis and Attitude. — In a recent work published in 
Mexico {La Vie sur les Hants Ptateau.x), which won the Hodg- 
kins" prize of the Smithsonian Institute, Herreta and Lope devote 
a chapter to the treatment of tuberculosis by altitude, noteworthy 
in many respects. They find that statistics show that not only in 
men but in lower animals tuberculosis is decreased in high re- 
gions. In 18S5, out of 73.000 cattle killed in the general abattoir 
of the City of Mexico, only forty-five were tuberculous. This fav- 
orable effect they attribute to the higher solar illumination in high 
altitudes and the dryness and coolness of the atmosphere as work- 
ing against the existence of microbes. The benefits of rarefied air 
in consumption are given by the authors from their experimental 
and other observations, as follows; (i) Lessening pressure in- 
creases the circulation of air in the lungs, dilates them and obliges 
torpid parts to functionate. (2) Lessening pressure determines a 
greater quantity of blood in the lungs. (3) Lessening pressure 
permits a uniform distribution of blood, regulates its circulation 
and combats congestion. (4) Lessening pressure diminishes in- 
trapulmonary tension in general and particularly intravascular 
tension. (5) Augmentation of red and white globules. (6) Des- 
iccation of mucous surfaces; the favoring of evaporation, besides 
experiments on animals, observations of actual cases of tuberculo- 
sis, treated by rarefied air, are reported by the authors. Of 13 
patients thus treated only i lost weight, i remained stationary, and 
II notably increased, i increasing 300 grams in one day. In none, 
either healthy or tuberculous, were the alarming symptoms de- 
scribed by Paul Bert experienced. 

3 Gardiner, Amer. Jour. 0/ tlie Med. Sciences, 1892 and 1897. 

■> Braithwaite"s "Retrospect of Medicine," p. 239, 1S99. 



io6 



CONSUMPTION IN COLORADO. 



[Medical News 



Light should be sunshine, or directly diffused from 
it, and with as little cloudy or white light as possi- 
ble. With these qualities of light and air, we have 
at our command the most powerful agents known 
for the cure or arrest of pulmonary phthisis, and 
these perfect atmospheric conditions are found only 
upon the dry, high plateaux of the world. Some of 
the qualities spoken of are found at the seashore, 
some in low elevations, as in a desert atmosphere; 
but for all the qualities mentioned in both light and 
air, altitude and dryness must be present. The ef- 
fects of sunlight upon germ life are well-known to 
all, and recent observations have shown that a par- 
tial absence of light tends to, and even does, de- 
velop consumption, when the air supply and other 
conditions remain the same.' Then, too, the direct 
solar rays are now known to penetrate live tissue and 
exert their influence as germicides. Experiments 
by Koch, Downs, Blunt, Duclaux, Esmarch, and 
Arloing are cited by Abrams — all tending to show 
the power and p_netration of solar rays, their effect 
as a stimulant of cellular life of plants and animals in 
health and disease, and their power as a cure. There 
is also good reason to believe that the solar rays pass 
through ordinary clothing and have a stimulating ef- 
fect upon capillary circulation, and nerve endings. 

A climate which has all the qualities of light and 
air that I have mentioned, ought to present ideal 
climatic conditions for the cure of consumption. In 
Colorado these climatic conditions do exist. Not 
only is there an average of fifty per cent, more sun- 
shine every day in Colorado than in any State east 
of the Mississippi Kiver, but the soil, temperature, 
and dryness of the air permit the pulmonary invalid 
to take advantage of these conditions. A simple ex- 
periment illustrates atmospheric light penetration in 
Colorado: expose several films in a camera (time 
exposure), and then under the same conditions in 
regard to films, time, sunlight, etc., expose the 
other half of the films at sea-level, or at the sea- 
shore, and the latter set of films will be found to be 
fogged from under exposure, the more dense air not 
allowing light to penetrate as easily as in Colorado. 
It is probably this property in the air of Colorado 
(dermithisity or thinness) that removes color so 
rapidly from all dyed fabrics, tans the exposed skin 
so easily, and allows the sun and diffused light to act 
so powerfully as a germicide. The practical point 
is to utilize this light and air in the best possible 
way for our patients in Colorado, or in all sections 
of the country having these climatic advantages. 

To ascertain the time spent out of doors by the 
average invalid in Colorado Springs I have departed 

' Robinson, "Climatology of Nudity," Trans. Amer. Climato- 

logical Asso.y p. 233, 1898. 



somewhat from the method of making meteorolog- 
ical tables, which show merely the number of days 
suitable for him to be out, and have compiled a list 
giving the time an average invalid actually spends 
in the open air. Meteorological tables, no matter 
how carefully compiled, give but a limited idea as 
to certain climatic details. Temperature is fre- 
quently misleading, as in Colorado the dry air allows 
an outdoor life at temperatures that would in a more 
humid climate be impossible or dangerous, while 
such climatic factors as dust are not noted in ordi- 
nary tables; and so on. This chart has been com- 
piled from an average of observations taken during 
the time from December 16, 1898, to April 19, 
1899. This was to make as severe a test as possible, 
as it is during these months we have in Colorado our 
most inclement weather. As last winter and spring 
were of unusual severity, in fact from all I can learn, 
the worst weather for any length of time of which 
we have a record, one can see that in this chart 
no flattering picture is drawn regarding our 
winter weather. By average invalid I mean those 
who are too ill to exercise by horseback-riding, 
cycling or golfing, or even walking, except very 
slowly, and yet are able to be up and about, 
and to spend considerable time out of doors, pro- 
vided they are protected and can sit or lie down. 
The time spent out doors can be regulated to a fine 
point in a sanatorium, but I refer to invalids who are 
in their own homes, in hotels or boarding-houses. I tell 
these patients, as most doctors do, that they must be 
out all they possibly can. I specify the hours and 
arrange the details of shelter, etc., selecting the win- 
ter months, as that is the season when an open air 
life become so necessary to the pulmonary invalid, 
for he feels the cold and will instinctively choose the 
warm and often close air of a room, inhaling furnace 
gas, dust, and germs. In summer it is, on the con- 
trary, an easy problem to induce patients to live an 
outdoor life; then all nature beckons to one, and 
even indoors the air is fairly pure by comparison, 
owing to the open doors and windows and the ab- 
sence of artificial heat. I find that the average in- 
valid spends outdoors daily about five hours, either 
on a piazza, driving, or at times walking a little. 
If the air and light are as important curative agents 
as I have stated, then five hours daily outdoors are not 
enough; we should aim at twenty-four hours. If we 
desire the best results we cannot afford to waste a 
single hour in fighting such a disease as tuberculosis. 
Few people realize the vast difference that exists be- 
tween a so-called well-ventilated room and the open 
air; the former is enough to kill an Indian.' 

' "Environment in Its Relation to the Progress of Bacterial In- 
vasion in Tuberculosis,'' ^w<r.yOT<r. ^///i? Med. Sciences, in\y. 



July 22, 1899] 



CONSUMPTION IN COLORADO. 



107 



The experience of one who has just returned to 
his ordinary habits from a life of several weeks spent 
entirely in the open air illustrates this. No matter 
how well ventilated the room in which he sleeps, it 
will seem close and a cold in the head is apt to re- 
sult. A simple experiment seems to me to bear 
closely on this subject. Take a piece of fresh veni- 
son or any meat and hang half of it in a room pro- 
tected by fly screens, hanging the other half on top 
of a pole in the open air in the sun; even if this is 
done in the months of July or August the meat out- 
side will remain fresh for weeks, while the meat in 
the room will spoil in a day or two. This is, of 
course, in Colorado, but I think the analogy be- 
tween this meat-test and a septic process in the 
lungs a very close one. The piazza life in Colorado 
can be made most attractive and comfortable, and a 
piazza can be arranged, as one in my house is, with 
a stove and blinds, furnished with rugs, bed, etc., 
and enclosed with glass on the north. In this way 
we offer an inducement to be out of doors, it is not 
taken as a task, and the nights also can be spent in 
pure air. 

A life on a ranch in Colorado would seem to offer 
to the invalid an ideal method of being in the air 
and light, and I have at present some patients who are 
certainly improving rapidly on ranches. But they 
do not represent the average invalid, as they are se- 
lected cases, especially adapted for the life, with 
youth, strong digestion, and entire absence of fever, 
making the experiment worth the risk. I practised 
medicine at one time for several years among ranches 
in Colorado, Wyoming, and parts of Utah, and my 
experience has been that it is all a well man can do to 
digest the food that is eaten on most ranches, since it 
is with hardly an exception poor food, poorly cooked. 
Ranch houses, too, are built without regard to 
sanitation, while the temptations to overexertion, 
exposure, etc., are constant. Their isolation is to 
many a great drawback, meaning, as it does, the 
difficulty of obtaining medical advice if taken sud- 
denly ill; and no amount of fresh air can compen- 
sate for such disadvantages. The life in a boarding 
house or in their own homes, with the constant use 
of the piazza, is probably the most practical arrange- 
ment for the greatest number of invalids and is the 
plan used by at least ninety per cent, of all invalids 
in Colorado Springs. 

1891. Also Trans. Col. Stale Med. Soc, p. 321, 1894. Dr. Bull: 
"I have attended the Indians both here among the Sioux and in 
Idaho among the Bannocks. I have known many agency physi- 
cians and have talked with them. All agree that the older Indians 
say that they did not have consumption among them when they 
lived in tepees and in the open air. But as civilization advanced 
among them the Government has constructed log cabins and small 
frame houses for them, and they have given up the tepee for a short 
time in the hottest weather in summer. Now we have consump- 
tion the most prevalent disease. More than half of the deaths are 
from it." 



I consider that for a certain number of patients a 
life in a tent is really the nearest approach to the 
ideal life for a consumptive; I mean of course, with 
careful selection of the patient for such a life, and 
then a careful selection of tent, camping-site, etc., 
so essential to success. To most people a tent sim- 
ply means what is ordinarily used in camping out, 
and it is this limited knowledge of tents that has 
brought them into disrepute with many physicians. 
The tent generally used is too low, made of thin 
duck, often without a floor, without proper artificial 
heat and is pitched in the open, becoming like 
an oven in the Colorado sunshine. Above all, such 
a tent has no proper system of ventilation and this 
is important, since a tent never ventilates itself by 
air coming through the canvas, as some people seem 
to think. The tent I have in mind is the result of 
considerable evolution in tent building, and although 
I have not yet been able to demonstrate its use with 
a large number of patients, I have myself lived in it 
both in summer and in winter, during rain and 
snow storms and for several weeks at a time. It is 
made of very heavy duck (12 oz,), is circular in 
shape, 1 8 feet high, 1 6 feet in diameter at the floor, 
with a wall 5 feet, 6 inches high. The top termi- 
nates in an iron ring i foot in diameter, to which the 
canvas is fastened, thus forming an outlet for heated 
air always open. The tent is supported by a center 
pole to which the ring is attached, and the tent can 
thus be elevated or lowered or its tension changed 
from within by pulleys. The floor is raised 8 inches 
from the ground, and is in 8 sections, thus being 
easily moved. The lower edge of wall is fastened 
several inches below the floor, i inch from it all 
around; this is to provide at all times an inflow of 
air that is gradual and without a draught, since this 
inch space m a circular tent represents an area of 
about 600 square inches, and the hole in the top for 
outflowing air some 123 square inches. In this way 
the tent cannot be close and is ventilated automat- 
ically and constantly. In other words, it is a circu- 
lar tent, the bottom of the canvas forming a circle 
around the wooden floor but one inch from it all 
around and a little below the floor. This open space 
between floor and sides of the bottom of the tent 
allows air to flow into the tent at all times, while the 
hole at the apex or top of the tent allows air to flow out 
all the time. In this way the tent always ventilates 
itself day or night, with door shut or not, or when 
heated or not, or in any weather. 

As the air has to turn a corner to enter the tent, 
it cannot come as a draught and as it enters through 
all the inch space surrounding the tent it enters 
slowly and without force, being evenly distributed 
but coming through collectively a large area, 600 



io8 



ARREST OF DEVELOPMENT. 



[Medical News 



square inches. The tent is easily heated by a wood 
or coal-stove, and yet in warm weather the constant 
interchange of air keeps it cool even without a fly. 
This tent should be fitted up in every way like a 
room. Cooking need not be done in it, but can easily 
be provided for at some house nearby. Such a tent 
can be lived in for at least eight months in the year 
in Colorado at 6000 feet altitude, and in winter can 
be transported, if necessary, to some warmer climate 
south. The advantages of tent life are plenty of 
fresh air and diffused light, all of the twenty-four 
hours taken without effort. The psychological effects 
of such a life cannot be told here, but that it is a 
constant mental rest, that the novelty charms, and 
that a certain something, possibly the awakening of 
the hunting and migratory instinct inherited from 
countless generations of primitive ancestors does af- 
fect beneficially the nervous system of the phthisical 
is undoubted. 

The points I have endeavored to emphasize are that 
light and air are to- day the most powerful agents we 
have for the cure of pulmonary consumption; that 
this fact is often overlooked, and that attention is 
paid to cures of much less value; that the most perfect 
qualities of light and air are only found on high, dry 
plateaux of over 4000 altitude, and that, under such 
climatic conditions, not only is the quality of light 
and air more perfect than elsewhere, but the avail- 
able quantity taken is in e.xcess, as it is practical for 
the patient to be out and obtain it; that if possible 
a pulmonary invalid should be out doors every hour 
of the twenty four, as indoor air is not a cure for 
phthisis, and that a piazza life can be arranged for 
and made as comfortable as in a room. Ranching, as 
generally utilized, is a dangerous life for the average 
invalid, owing to bad food, exposure, over e.xertion, 
etc. A selected number of patients can be induced 
with benefit to live a tent life provided the tent is 
jiroperly selected and managed on the plan I have 
suggested. Thus, while avoiding the ills of civili- 
zation from which our patient is escaping, we so 
control the new environment of nature as to avoid 
all its dangers, and obtain all its benefits. 



CLINICAL MEMORANDUM. 



ARREST F DEVE LO P MEN T; SPINA BIFIDA, 
AND CLEFT PALATE. 

By W. a. McFARLANE, M.D., 

OF SPRINGVILLE, N. Y. 

Spina Bifida. — In looking up the literature on this 
subject, I find that nearly every article deals with the 
surgical treatment of this affection without much refer- 
ence to its etiology. The following cases have some 
points of interest: 



Mrs. X., aged twenty-four years, married, primipara, 
on August 5, 1883, gave birth to a female child that 
presented a tumor in the lower dorsal region of the spine. 
The babe died in convulsions four days later. During 
the sixth week of gestation the mother had received a se- 
vere injury to the spine by having a chair pulled from 
under her as she was about to sit down. This injury af- 
forded a very good explanation for the cause of the de- 
formity of the child. 

On October 18, 1886, she gave birth to a second 
daughter who was deformed in the same manner as the 
first. The child lived two weeks and died of exhaustion. 
The mother had complained of some pain in her back 
during her second pregnancy, due probably to the injury 
which she received while carrying her first child, for she 
had not met with an accident during her second preg- 
nancy. I attended her in her second confinement, but 
not in the first. In the case of the second child the tu- 
mor was situated in the lower dorsal region, was about 
2>^ inches in length by two in width, and was elevated 
above the surrounding tissues about three- fourths of an 
inch, was transparent, and of a dark-reddish or purple 
color. 

I applied a truss with a concave pad, simply for the 
purpose of protection. This comprised the treatment, 
the parents objecting to any operation. The father and 
mother were very much disappointed in the result of this 
pregnancy, and I was immediately called upon for an 
opinion as to the possibility or probability of their ever 
having a child that would be all right. My experience 
was msufficient, neither could I find anything in books nor 
journals that would warrant me in giving advice either 
way. In my dilemma I counseled with Dr. Skene of 
Brooklyn, my former teacher, stating all the facts in my 
possession, and his reply was "to try again, for she might 
do better next time." He also advised the use of the 
syrup of the iodid of iron when she became pregnant 
again, during the second, fourth, sixth, eighth, and ninth 
months. When she became pregnant again this treat- 
ment was adopted and carried out. On May 14, 1890, 
I had the satisfaction of delivering her of a female child, 
perfect in every way. 

To add to the difficulties of deciding this important 
question there was a family history which was not good. 
A sister and her daughter had heart disease, and in the 
daughter's case was probably congenital. She afterward 
died of chronic Bright's disease at the age of sixteen 
years. A brother's child was born with an amputation 
of the left forearm near the elbow. 

Dr. John Ashhurst, in Pepper's "Practice," mentions 
the fact that Salzman observed spina bifida in two chil- 
dren born of the same mother, and Camper noticed it in 
twins. Dr. L. Emmett Holt of New York reports a case 
in the AVrf York Medical Journal, Vol. 46, in which the 
first and second child had spina bifida, the mother 
afterward giving birth to a healthy well-formed child. No 
statement is made, however, in regard to her treatment. 
In the Medical and Surgical Reporter, Vol. 58, Dr. 
Samuel Wolf of Philadelphia reports a case in which the 
mother gave birth to two children having the malforma- 



July 22, 1899] 



THERAPEUTIC NOTES. 



109 



tion. He outlined a plan of treatment which consisted 
in a careful regulation of the diet, the administration of 
hypophosphites. lactophosphate of lime, cod-liver oil, etc. 
He was unable, however, to test his plan of treatment on 
account of the patient's moving out of his district, but he 
learned later that she ga%'e birth to one child, at least, 
that was not deformed. These are the only cases I have 
been able to find reported in which a mother has given 
birth to two children having this deformity. 

Cleft Palate. — Mrs. Y., on September 2, 1S94. ga%-e 
birth to a male child having cleft palate. It was weak 
and died four weeks later. August 2, 1896, she was 
confined again. This child was perfectly formed, and is 
living at the present time and is in good health. During 
her second pregnancy she received treatment which con- 
sisted in the administration of the syrup of the iodid of 
iron, the same as in the case preceding, and the results 
were entirely satisfactory. She was confined again on 
April 20, 1898, at seven months. This child had talipes 
varus of the left foot, and in place of the fourth and fifth 
toes there was a gelatinous mass extending back to the 
middle of the metatarsal bones. She had taken the iron 
irregularly. The family history of the mother was not 
good ; an uncle had died of locomotor ataxia, her mother 
had goiter and died of apoplexy at fifty years of age. 
The mother of the child had a sister who had hvsteria. 



THERAPEUTIC NOTES. 



Treatment of Bright s Disease. — N'ESTOR TiRARD ("Al- 
buminuria and Bright's Disease") inculcates the following 
principles of treatment of this disease : In the acute form 
of nephritis rest in bed, restricted diet, the wet pack, dia- 
phoretics and cathartics are to be employed during the 
first few days, until an increase of the amount of urine 
voided and the absence of hematuria denote that the 
renal engorgement has subsided. Until this occurs, ni- 
trogenous food and active diuretics are contraindicated. 
A strict milk diet is administered when possible, but in 
case digestive disturbance is produced thereby, small 
amounts of broth of chicken, veal or mutton may be 
added or substituted. Persistent vomiting should be com- 
bated by small doses of hydrocyanic acid, preparations 
of bismuth, drop doses of tincture of iodin, or small 
doses of creosote or carbolic acid. 

In coma or convulsions active cathartics, as croton oil, 
are to be administered, and if persistent headache is pres- 
ent, small doses of calomel combined with compound pill 
of colocynth are given. The wet pack is preferred to the 
hot-air or vapor bath, as being more convenient of appli- 
cation and of equal efficiency. Restlessness and insom- 
nia are to be combated with the bromids. hyoscin and, 
sometimes aconite. If anasarca exists to such a degree 
that relief is not afforded by purgatives and the wet pack. 
the skin over the malleoli may be punctured to allow the 
serum to drain off. Digitalis and caffein are indicated as 
diuretics after the hematuria has disappeared. During 
convalescence exposure to cold, and any muscular or 
mental strain must be avoided. Strict attention must be 



paid to the diet as long as albuminuria persists, and the 
non-astringent preparations of iron and arsenic should be 
given as tonics. 

In chronic nephritis, if any cause can be found — as 
malaria, syphilis or suppuration — this must be treated, 
using mercury with great care, should it be indicated. 
In cases exhibiting excessive dropsy and muscular weak- 
ness, rest in bed is indicated; but when the patient's 
strength is good and there is but slight anasarca, a moder- 
ate amount of outdoor exercise is beneficial. The ques- 
tion of withholding albuminoids from the diet must be 
decided by the effect produced on the individual patient, 
though no nitrogenous food should be allowed if hem- 
aturia exists. The only limit to the amount of albumin- 
oids to be allowed is the ability of the patient to digest 
them. Although sometimes a strict milk diet will cause 
the albuminuria to disappear, it is not, as a rule, wise to 
confine the diet too strictly to milk. If the patient's 
habits have been such that a bad effect is produced by a 
complete deprivation of alcohol, a small amount may be 
allowed, but it must be always largely diluted and taken 
only at meal times. If these conditions are observed, 
the form in which it is taken is of slight importance ; and 
if no loss of appetite or indigestion results from the with- 
drawal of alcohol, none should be given. Diminution in 
the amount of urine voided may often be corrected by 
copious draughts of water, or, if the patient can bear it, 
of milk. The cardiac tonics — strophanthus, digitalis and 
caffein — are indicated, and the alkaline diuretics if there 
is no hematuria. Dropsy is to be treated by purgatives, 
such as the compound powder of jalap and the salines, 
given in doses to be regulated by the effect produced on 
the patient; by the carbonates and citrate of lithium and 
the citrates and tartrates of sodium and potassium : and, 
when the heart and lungs are in good condition, by small 
doses of pilocarpin given in connection with the wet pack. 
The same agents are to be employed in the treatment of 
uremic symptoms. Dyspnea should be treated accord- 
ing to its cause, engorgement of the lungs or weakness 
of the heart or uremic poisoning. The use of morphin 
is not recommended. Life in a warm, equable climate is 
to be desired and light and non-excitmg occupation should 
be followed if possible. 

Treatment of Ozena with Citric Acid. — Ha.MM {.Munch. 
Mdd. IVoclt., April 11, 1899) recommends the applica- 
tion of citric acid in ozena, as the best means of taking 
away the terrible odor, which not only disgusts all with 
whom the patient comes in contact, but also often de- 
stroys the appetite of the afflicted individual. Hence, the 
mere removal of the odor is often followed by a marked im- 
provement in the patient's general condition. The citric 
acid, however, has also a slight beneficial effect upon the 
nasal lesions. It can be used either pure, or better 
mixed in equal parts with sugar of milk. The nose is 
thoroughly cleansed in the morning, and the powder is 
then blown into it, and the insulflation is repeated at noon 
and at night. The deodorizing effects continue some 
days after the discontinuance of the powder, and as the 
citric acid has no harmful action, it may be used as often 
as is necessary. 



no 



THERAPEUTIC NOTES. 



[Medical News 



Liquid Thiolum to Relieve Pain. — NikuliN {Deut.Med- 
izinal-Zeituftg, April 17, 1899) has used pure liquid 
thiolum to relieve the pain of contusions, abscesses, acute 
and chronic gout and rheumatism, neuritis and myositis, 
finding it beneficial in promoting absorption as well as in 
stilling pain. In the acute cases the results fol- 
lowed more quickly than in the chronic ones. The thio- 
lum was painted upon the affected portion of the body 
with a brush, several coats being applied, and was allowed 
to dry. It was then covered with a bandage to keep it 
clean, and two days later another application was made 
if necessary. At the end of the treatment the excess of the 
substance was washed away with warm water or alcohol. 
In no case was any irritation of the skin observed, even after 
repeated applications of thiolum. 

Treatment of Acute Gastritis in Ctiiiuren. — The first step 
in the treatment of this disease is to see that the stomach 
is thoroughly emptied of all irritating matter (Pepper, 
"Keating's Cyclopedia," vol. v). If the child has not 
vomited very freely the stomach should be thoroughly 
washed out, either by lavage, or if that cannot be em- 
ployed for any reason, by administering warm water and 
ipecac. After the stomach has been well emptied no food 
must be allowed until the organ has become entirely quiet. 
Vomiting may be controlled by administering cracked ice 
or albumen-water. Calomel in minute doses should be 
given if an offensive diarrhea is present. Bismuth is often 
of use, but sometimes the cautious use of morphin is 
necessary. But the stomach will usually become quiet 
after the withdrawal of all food sooner than as a result of 
medication. Fever should be treated by sponging the 
body or by the tepid bath. Antipyretics should be used 
only in very exceptional cases. The return to the ordinary 
diet must be very gradual. 

Treatment of Pertussis. — CHENEY ("Keating's Cyclo- 
pedia," vol. v). The patients, of course, should be iso- 
lated and allowed to have plenty of fresh air both by day 
and night and should be allowed plenty of good nourish- 
ment. The drugs to be employed are : First, antiseptic 
agents, the best of which are the vapors of carbolic acid, 
cresolin and thymol, and quinin, which can be included in 
this class. It is very valuable, if the child can retain it, given 
in doses according to the age of the patient — ^■^- of a 
grain for each month and i yi grains for each year of the 
child's age — three times a day. Secondly, antispasmodics, 
of which the most useful is bromoform, which should not 
be given in solution but on sugar in a spoon, in doses of 
I drop every four hours, increasing the dose by one drop 
each day until an effect is produced. Antipyrin in com- 
bination with bromid of sodium is also of much value in 
the treatment, given in doses ol yi s. grain of the former 
to 2 grains of the latter, for a child of eight months ; i 
to 2>^ grains for a child of fifteen months, and 2 to 
3 grains for a child of from two years and a half to four 
years of age. Belladonna may be given in small doses, 
repeated until the physiological effect is produced. 

Fatal Poisoning by Benzine. — SpURR {Lance/, June 
3, 1899) records the death of an epileptic woman. 



aged twenty-six, fifty hours after taking about an ounce of 
benzine. Only a few cases of poisoning with this very com- 
mon substance have been reported. In most of them the 
symptoms have been of a narcotic character. In this in- 
stance the patient complained of a severe burning pain in 
the mouth and throat, and although she was given a 
strong emetic of mustard and water soon after the acci- 
dent, there was collapse rapidly progressing to a fatal 
termination. Swallowing soon became well-nigh impossi- 
ble. At the post-mortem examination the mucous and 
submucous coats of the esophagus, stomach, and duode- 
num, were found to be intensely inflamed, and in the 
duodenum there were erosions of the mucous membrane, 
but no perforation. The brain, lower portions of both 
lungs, the liver, spleen, and kidneys were all intensely 
congested. The absence of narcotic symptoms was 
thought to be due to the prompt administration of the 
emetic. 

Xeroform, Externally and Internally. — BarSKY {Rev. de 
Therap. Medico-Chir., May 15, 1899), after using xero- 
form in 417 cases (in 34 of them internally), formulated 
the following conclusions in regaid to its action : (i) Xero- 
form although not a powerful antiseptic is a most service- 
able one. It is decomposed by the alkalin fluids of the 
body into bismuth and tribromophenol. The former 
makes an insoluble compound with ptomains and renders 
them innocuous, and acts mechanically to prevent the en- 
trance of microbes. The latter constituent has a germi- 
cidal action. (2) It is not changed by light, air, or heat. It 
can be sterilized repeatedly up to 120° C. without alter- 
ation. (3) It is not only without odor, but it dispels the 
bad odors which come from ulcers of the skin, or sup- 
purating cavities connected with the genitals or alimen- 
tary canal. (4) It possesses drying properties to a high 
degree. It does not form a crust over a wound, nor 
stick to the surface, but is carried with the discharges 
into the dressing. (5) It has an analgesic and a hemostatic 
action, and favors the growth of healthy granulations, and 
so hastens the healing. (6) It is not at all toxic, and does 
not exert any irritation either upon the wound or the sur- 
rounding tissues. It was used in the form of a powder, 
as a salve, in gauze, and in bougies. Internally it was 
given in an emulsion, the dose being from 3 to 8 grains, 
three times a day. It was prescribed for acute and 
chronic gastric troubles, and for urticaria. 

For an Early Morning Diarrhea. — Lemoine {Nord Med., 
p. 86, 1899) thinks that the morning diarrhea, occurring 
especially in nervous individuals with an excess of hydro- 
chloric acid, can be favorably affected by a suitable diet. 
Roast or broiled meat should be taken at supper time, 
and no vegetables. He gives his patients 2 to 4 grams 
( 3 ss to 3 j) of bicarbonate of soda before the evening 
meal, and at bedtime 10 grams ( 3 ijss) of gelatinized 
phosphate of chalk, either in milk or in syrup. 

Diarrhea after meals occurs also in hyperchlorhydric 
persons. They should be put upon a correct diet, and 
should lie down after eating. Each meal should be fol- 
lowed by 2 or 3 drops of acetate of opium in a little 
water. 



JULV 22, 1899J 



STREET DIRT AND TETANUS. 



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SATURDAY, JULY 22, 1899. 

STREET DIRT AND TETANUS. WIT H SON! E 
REKARKS ON TREATMENT. 

During the latter part of last week and the begin- 
ning of the present one a number of tetanus patients 
have been under treatment at various New York City 
hospitals. A number of deaths from the disease 
have been reported in the city itself, and from its 
suburbs. We have had quite an epidemic of what 
the newspapers call lockjaw. It is not unusual at this 
time of the year and the history of practically all of 
the cases is the same. There is a wound from a 
firearm or piece of fireworks on the Fourth of July. 
The lesion heals usually with little difficulty, to re- 
open some eight days to two weeks later, though 
sometimes it does not, when the symptoms of tetanus 
show themselves and the case either runs a rapidly 
fatal course or convalescence is very protracted, and 
in most instances some "mark" of the disease re- 
mains forever after impressed upon the sensitive 
nerve centers. 

The development of tetanus after certain kinds 
of wounds inflicted in city streets is not uncommon. 
It occurs especially after contused wounds accom- 



panied by slight laceration of the skin, or upon 
what may be called simply lacerated wounds. The 
bacillus of tetanus is absolutely and unalterably 
anaerobic, that is it grows only in the absence of 
o.xygen. It is not like so many other anaerobic 
bacilli, facultatively aerobic, or capable of at least 
some growth in the presence of oxygen. It is only 
when the bacillus somehow becomes buried in the 
tissues away from all contact with the air that it 
finds a favorable nidus for growth in the human 
organism. Lacerated wounds or contusions with 
slight abrasions of the skin furnish just such an 
opportunity for growth away from .the air. It 
seems that the dust of city streets, especially in the 
summer time, usually contains tetanus bacilli, so 
that the primary element necessary for the produc- 
tion of the disease is practically always at hand. 

Notwithstanding that we possess an antitoxic 
serum that is effective in preventing the develop- 
ment of the disease in animals, its employment has 
done very little good in human beings. Cures 
have been reported from its use, but a certain num- 
ber of tetanus patients always recover and there is 
more than a suspicion that it is mostly in the cases 
more or less chronic from the beginning, and in 
which recovery often takes place even under old 
methods of treatment, that the serum seems to be 
effective. Certain it is that a number of individuals 
afflicted with the acute variety of the disease die 
despite the very generous employment of the serum. 

Even in the case of animals the fact of the matter 
is that the animal cannot be saved by ordinary sub- 
cutaneous injections of tetanus antitoxin if distinct 
symptoms of tetanus are already present. The in- 
jection to be effective must be given before the 
symptoms begin to show themselves. Recently it 
has been shown that intracerebral injections of teta- 
nus antitoxin are effective in curing the disease in 
animals even when symptoms are at their height. 
A certain number of cases of tetanus in human be- 
ings have also been treated in this way, and with 
good results as far as the tetanic convulsions are 
concerned, though we do not always know the ulti- 
mate outcome of the case. Dr. Gibb reports a case 
in the British Medical journal for July i, 1899, in 
which, after the cure of his tetanus, the patient 
died of cerebral abscess eight weeks after the injec- 
tions had been given. 



SERUM-THERAPY IN DIPHTHERIA. 



[Medical News 



This method of intracerebral injections undoubt- 
edly has its objections. It is a serious operation, 
and its sequelse are olten apt to be serious even 
with the most careful precaution. Its employment 
seems to be justified in very acute cases, however, as 
the disease in such cases is practically always fatal. 
The ideal method of treating tetanus, however, is 
the one we quoted from Professor Landouzy of the 
University of Paris in reviewing his book on "Serum 
Therapy" ("Notable Books," Medical News, 
March i8, 1899). He suggests the use of prophy- 
lactic injections of tetanus serum in cases of suspi- 
cious wounds. Tetanus antito.xin has of late years 
been made of such high antitoxic potency that it 
requires but the injection of a few drops of the serum 
to absolutely preclude the possibility of the develop- 
ment of tetanus. This procedure is certainly worth 
trying in the case of all contused and lacerated wounds 
that have been exposed to contamination by street 
dirt, and especially when they have been inflicted 
by firearms. It could do no harm even if there 
were no tetanus germs present. The serum, though 
of such high antitoxic potency, is absolutely innocu- 
ous. It would certainly save a great many lives 
and save the individuals, too, from a most horrible 
death in the midst of the conscious agony of tetanic 
convulsions. No one has yet, we believe, reported 
the use of this method in America. It seems 
distinctly worthy of such a trial. 



SERU M-THERAPY IN DIPHTHERIA. 

There are still some ultra-conservatives who think, 
or pretend to think (the latter is not an unusual state 
of mind, and may easily be assumed in perfect good 
faith in cases in which a public statement has once 
been made on a subject) that diphtheria serum has ac- 
complished nothing in reducing the mortality from 
the dread disease. To these the statistics of the New 
York Board of Health and of the European cities 
where the remedy has been properly tested, as pre- 
sented by Dr. Biggs in this issue, cannot be expected to 
bring conviction. A few others, who are so obsti- 
nate in their misoneism that a new therapeutic prin- 
ciple is an obvious impossibility, may be added to 
this list. To all others the specific curative proper- 
ties of diphtheria serum is now a matter of absolute 
science. 

Yet the opposition to diphtheria antitoxin has 



not been without its good results. The jealous 
watchfulness over mortality statistics by the uncon- 
vinced has had its beneficial effect in making those 
statistics accurately representative of facts, and has 
had its influence in producing constant improvement 
in the quality of the serum supplied. The notoriety 
at once given to complications seemingly induced 
by serum, or to sequelae of its administration, has 
led to a thorough investigation of these unlooked- 
for effects, and has brought about their more and 
more effective amelioration. It is well for scien- 
tific medicine, especially for therapeutics, that the 
conservative element in the profession is so strong. 
It saves many a premature acceptance of what seems 
at first a useful remedy. What good grounds there 
were for a reluctant conservatism in the acceptance 
of diphtheria serum as a remedy, may be judged 
from the fact that its first much-vaunted successes 
were really not due to the antitoxin at all, but to ex- 
pectant treatment, for the serums first employed 
were of such low antitoxic value (fifty antitoxin units, 
and even lower) that whoever should pretend now 
to base statistics on the use of corresponding amounts 
would be laughed to scorn. 

It is evident, however, that the day for true con- 
servatism in the matter has gone by. Hesitation 
now degenerates into old fogyism — misoneism is, we 
believe, the newer and more elegant term for this 
halting entanglement in ideas that have been out- 
lived. The seal of professional approval has been 
put on the new remedy not by any one school or 
clique in medicine, and the hearty approval has not 
been dictated by national or other extraneous mo- 
tives. It has been the result of careful observation 
in hundreds of thousands of cases all over the world. 
Statistics can still, in certain places, be so manipu- 
lated and discussed, that there remains in some 
minds just a shade of doubt, but this is only true be- 
cause prejudice exists. The sentiment of the pro- 
fession on the subject all over the world is clear, 
beyond the shadow of a doubt. 

We quoted some time ago in this column the 
Chicago diphtheria statistics, and we are glad to be 
able to give this week the New York statistics, each a 
striking contribution to the literature of the success of 
antitoxin therapy. The boards of health of the two 
cities have deserved well of the profession and of 
modern scientific medicine, for their work in the 



July 22, 1899J 



THE PLAGUE IN THE MIDDLE AGES AND NOW. 



113 



collection and collation of the statistics, and for the 
thoroughly scientific manner in which the subject 
has been worked up and convincing conclusions 
evolved. 

THE PLAGUEINTHE MIDDLE AOESANDNOW. 

The fearful epidemics of the plague which swept 
Europe at different times, from the Sixth to the 
Seventeenth Century, filled the public mind with a 
horror from which it has never freed itself, and which 
modern science has done little to remove. In the 
Middle Ages the people feared an unknown some- 
thing lurking in the air or in the touch of the sick 
or in their food. They had good reason to fear it 
for it seized upon them in times of epidemic and 
after a few hours' illness they were dead. They 
filled their streets with smoke, they bore burning 
pitch and sulphur through the sick-rooms, they 
rubbed the walls of their dwellings with chalk, they 
washed their food in fresh water, they withdrew from 
all intercourse with their neighbors, and fled at the 
sight of a stranger, and if they had to go into the 
streets on some unavoidable errand, they wrapped 
themselves in flowing wide-sleeved robes which 
they could cast aside when they came to their own 
■doors. Others rubbed themselves with oil, because 
it was believed that in Egypt oil-bearers seldom took 
the disease. Others followed the advice of Boccacio 
and warded off the "black death" by laughter and 
song and jest. But merry-making in the face of 
death demands a lot of courage, and if that was 
lacking, it had to be gained by stimulants, so that 
the sound of revelry often mingled on the night air 
with the rattle of the hurrying dead-cart. 

We pride ourselves on our scientific knowledge 
and our freedom from superstition. Men with 
bravery as true as that of the soldier charging up a 
hill against the fire of the enemy have tracked this 
black monster by caravan route and by ship back to 
its home in India and China, where they watched 
its comings and goings until in Hong Kong in 1894 
they finally caught it and named it. It was once 
an unknown evil; now it is called "bacillus pestis." 
Familiarity with its manner of living and multiply- 
ing has begotten a certain amount of carelessness 
perhaps on the part of investigators, a carelessness 
which cost Vienna dear last fall when the death of a 
laboratory attendant who had charge of some ani- 



mals which had been inoculated with the plague ba- 
cillus was quickly followed by the death of the 
physician and nurse who attended him, and all 
Europe knew that the plague had broken out in its 
very center. Vienna was in a panic, and the un- 
reasoning fear and the hasty erection of barracks for 
the reception of possible victims to the disease, the 
burning of everything suspected of having come into 
contact with "bacillus pestis," the closing of all 
hospitals to students, and the appointment of royal 
commissions to consider ways and means of prevent- 
ing the spread of the disease, all show that the 
superstitious fear of the Dark Ages is not dead, but 
only sleeping, and that a breath from Asia would 
arouse it to all of its former cruel activity. 

.\re we really in danger of such epidemics as have 
prevailed in past times? This momentous question 
is as yet without a satisfactory answer. Europe has 
had two great visitations of the plague, one in the 
middle of the Sixth Century, beginning in Egypt 
about the year 542, spreading through Constanti- 
nople where ten thousand people are said to have 
perished in one day, through Liguria, Gaul, and 
Spain, and ultimately all over Europe, having lasted 
a half century, during which time it caused the 
death of some millions of inhabitants. The second 
great epidemic was supposed to have originated in 
China in 1334, and after spreading through India 
and. Persia, it reached Europe in 1347, and twenty- 
five million people fell before it during the next four 
years. Since that time there have been many 
epidemics especially in the Eighteenth Century, 
numbering their hundreds of thousands of victims 
but these epidemics have all been minor ones in 
comparison with the two great ones spoken of above. 

If Europe has been free from this "black death" 
for nearly a century such has not been the good 
fortune of Africa and Asia. Little is known about 
the conditions of health in the centers of these two 
continents, but there is reason to believe that there 
are at least four regions where the "bacillus pestis" 
has its permanent abode, and from which it sallies 
forth from time to time to taste new blood. One of 
these is in Central Africa, one in Arabia, one in 
Mesopotamia, and one in Central .\sia, from which 
the Chinese epidemics arise. 

Whatever may be the means we possess to-day for 
the prevention of the spread of the disease, and as 



114 



ECHOES AND NEWS. 



[Medical News 



they have not been fully tested it is not certain what 
their real value is, our means for curing those who 
fall sick with the disease are not much better than 
the Middle Ages possessed. It is estimated 
that in the Hong Kong epidemic of 1894 ninety-five 
per cent, of those who contracted the disease died. 
In other places the mortality has ranged from eighty 
to ninety per cent. There are no reliable records 
of the percentage of mortality of the epidemics of the 
Fourteenth Century, but it could not have been 
much worse. 

It is encouraging that the recent outbreak in 
Vienna was so completely controlled. As far as 
it goes this speaks well for our knowledge of disin- 
fection. Unfortunately it does not go very far 
toward proving our superiority to "bacillus pestis. " 
The conditions were not ripe for its coming. It 
had been carried artificially under favorable condi- 
tions of warmth and moisture and nourishment in 
glass tubes from India to Vienna. It was an exotic 
there at that time, and'no doubt was as tender as ex- 
otics usually are. At the times of epidemic the con- 
ditions for its growth everywhere out of doors have 
been favorable, else it could not have naturalized 
itself so rapidly. Hence it is unsafe to argue that 
because this sporadic development of plague did not 
spread further that a natural epidemic could be as 
easily stopped. There are men who have been 
fighting the plague in India for the last two years, 
who say that such would not be the case. They 
argue if the extraordinary powers given to the sani- 
tary experts in India — powers which allow them to 
burn whole villages and to keep the inhabitants ab- 
solutely isolated — did not prevent the spread of the 
disease that Europe with its solidly built houses 
would be even more helpless before a real epidemic. 

People often express surprise that any one can work 
in a laboratory with deadly germs of all descriptions 
and not contract some disease. To the initiated the 
habits and possibilities of attack of the different ba- 
cilli are as well known as are those of serpents or 
tigers to keepers of a menagerie. Occasionally by 
an accident some one falls under a lion's paw or an 
elephant's trunk, and in a similar manner some lab- 
oratory worker contracts diphtheria, or typhoid, or 
cholera. These happenings, however, are pure acci- 
dents, and neither the menageries nor the labora- 
tories will ever close for the lack ofmen who are willing 



to disregard a danger which owes its power to their 
own carelessness. 



ECHOES AND NEWS 



The Plague at Alexandria. — Three cases of bubonic 
plague were reported at Alexandria, Egypt, July 9th. 
The inhabitants are said to be discontented with the sani- 
tary precautions and threaten trouble if the disease con- 
tinues to spread. 

Tetanus in 1898. — There were seventy-three deaths 
from tetanus in Greater New York last year. Of the 
number twenty-three occurred in the Borough of Man- 
hattan, thirty-four in the Borough of Brooklyn, and one 
in the Borough of the Bronx. 

Bubonic Plague on Shipboard. — It is reported by wire 
that the "City of Pekin" is quarantined at Nagasaki, and 
the American "Maru" at Yokohoma (both of the San 
Francisco-Oriental Line) with cases of bubonic plague 
aboard. Two deaths from this disease have occurred 
on the "Maru." 

The Progress of fellow Fever. — At Havana, Cuba, 2 
cases of yellow fever were reported July 6th. At Santi- 
ago from June 15th to July loth there were I48cases and 
28 deaths. Vera Cruz, Mexico, from June 29th to July 
6th, 25 deaths. On the bark "Dolores Romano" at 
Vera Cruz July 1st 7 cases were discovered. 

The American Electrotherapeutic Association. — This 
association will hold its ninth annual meeting at Washing- 
ton, D. C. , September 1 9, 20, and 21,1 899. Willard's Hotel 
has been chosen for the headquarters and special rates have 
been made for all interested in this meeting. Many able 
papers have been promised and a very successful scientific 
meeting is assured. 

Scarlet Fever at West Point. — A slight epidemic of scar- 
let fever broke out among the cadets at West Point, July 
nth. The prompt application of quarantine measures 
quickly brought it under control. During its sway the 
naval cadets from Annapolis on board the schoolship 
"Newport" arrived to pay a visit to the post. The quar- 
antine rules prevented their landing, and they sailed 
away, without having grasped the hands of their brothers 
in the army. At last report no new cases had appeared, 
and the dress parades had been resumed. 

The Buffalo Laboratory and the English Parliament. — In 
the English House of Commons, July i ith, in replying 
to a (|uestion of Sir Charles Cameron, the Parliamentary 
Secretary of the Foreign Office, said the attention of the 
Foreign Office had not been previously called to the fact 
that, owing to the deaths from cancer, the New York 
Legislature had endowed a laboratory at Buffalo to study 
the disease, but, the Under Secretary added, the 
British Charge d'Affairs at Washington, would forthwith 
be asked to furnish the Government with all possible in- 
formation regarding the institution. This recent interest 



July 22, iSggJ 



MEDICAL MATTERS IN NEW YORK. 



•IS 



in the Buffalo laboratory has been aroused by the state- 
ment that investigations now being conducted there 
point strongly toward the confirmation of the germ 
theory of cancer. The somewhat startling statistics pub- 
lished last winter by Dr. Roswell Park setting forth the 
prevalence of cancer in New York State have been seri- 
ously questioned. Dr. Park informs us in a personal 
letter that in view of this fact, he is having his statistics 
carefully scrutinized in their minutest detail by experts 
preparatory to a subsequent statement. 

Yellow Fever and Quarantine at Santiago. — General 
Wood in command of the Department of Santiago de 
Cuba is adopting heroic measures to stamp out yellow 
fever. An absolute quarantine against all officers and 
employees of the government, except those belonging to the 
department, has been established about the city. The 
mayor is directed to close all American hotels and saloons, 
to forbid liquor dealers to sell intoxicants to Ameri- 
cans, and to arrest all intoxicated Americans or loiterers 
in saloons. The principal hotels and saloons are desig- 
nated by name. The pack-trains have been ordered to 
establish camps outside the city, and all the troops have 
been moved to Songo, except one company at Morro 
Castle. The headquarters of all the departments have 
been moved to Crispo, and the railroad and steamship 
lines are forbidden to bring Americans into the city. No 
ships are permitted to touch at the wharves. The strictest 
regulations have been established for the protection from 
fever of the soldiers at Morro Castle. Supplies are to be left 
at a road depot, and will be taken to the soldiers by teams 
from the camp. No travelers will be permitted to 
leave without having undergone five- days' detention in 
camp. On July 12th Captain Thomas M. Woodruff, ad- 
jutant of the Fifth Infantry, died near Santiago of yellow 
fever. Captain Woodruff was a native of the State of 
New York, but was appointed a cadet at West Point 
from the District of Columbia. 

Letter from Major Harvard at Santiago Surgeon-Gen- 
eral Sternberg has received a letter from Major Harvard, 
Chief-Surgeon at Santiago, which gives an interesting re- 
view of the yellow-fever situation there. The letter is 
dated July 5th, and says : "Fever broke upon us suddenly 
almost without warning, the first case in a dirty lodging- 
house in town, but the second and third cases almost 
simultaneously in the barracks. We have no doubt that 
the city is infected in various places, but especially in the 
barracks lately occupied by four companies and band of 
the Fifth Infantry, from which have come the great ma- 
jority of our cases. The barracks and hospitals have 
been evacuated, as well as all other public buildings, and 
all our troops are in camps. The first two companies are 
now free from yellow fever, but the last two have con- 
tinued to furnish many cases. On the 2d and 3d inst. 
these infected companies were disinfected, and sent into 
the foothills, five miles away, where we expect good re- 
sults. Up to this evening we have about 104 cases, in- 
cluding 15 civilians, with total deaths of 23. Our gen- 
eral hospital is now under canvas, but I hope to be able 
to have a frame structure put up. All our cases with the 



exception of a Cuban, and a Spaniard, are Americans, 
and as all our troops are out of the city we necessarily 
expect a prompt decrease of the epidemic for want of 
material to feed upon. I have nothing but high praise 
for all the medical officers on duty in this city." 

Assignments of Volunteer Medical Officers to Regiments at 
Various /"os/s. — Volunteer officers of the Medical Depart- 
ment have been assigned to regiments as follows : To 
the Twenty-sixth Infantry, United States Volunteers, 
headquarters Plattsburg Barracks, N. Y., Major Charles 
F. Mason, surgeon; Captain Frederick A. Washburn, 
Jr., assistant-surgeon; First Lieutenant John E. Boyd, 
assistant-surgeon. To the Twenty-seventh Infantry, 
United States Volunteers, headquarters Camp Meade, 
Penn., Major Ogden Rafferty, surgeon; Captain James 
H. Hepburn, assistant-surgeon ; First Lieutenant Leon- 
ard K. Graves, assistant-surgeon. To the Twenty- 
eighth Infantry, United States Volunteers, headquarters 
Camp Meade, Penn., Thomas C. Chambers, surgeon; 
Captain S. Chase de Krafft, assistant-surgeon; First 
Lieutenant Allen J. Black, assistant-surgeon. To the 
Twenty-ninth Infantry, United States Volunteers, Fort 
McPherson, Ga., Major Charles L. G. Anderson, sur- 
geon; Captain James C. Minor, assistant-surgeon; First 
Lieutenant Lomax S. Anderson, assistant-surgeon. To 
the Thirtieth Infantry, United States Volunteers, head- 
quarters Fort Sheridan, 111., Major John R. McDill, sur- 
geon; Captain James J. Erwin, assistant-surgeon; First 
Lieutenant Albert H. Eber, assistant-surgeon. To the 
Thirty-first Infantry, United States Volunteers, head- 
quarters Fort Thomas, Ky., Major Joseph N. Henry, 
surgeon; Captain Abram L. Haines, assistant-surgeon; 
First Lieutenant Ralph L. Porter, assistant-surgeon. 
To the Thirty- second Infantry, United States Volunteers, 
headquarters Fort Leavenworth, Kansas, Major Frank C. 
Armstrong, surgeon ; Captain John W. Hereford, assist- 
ant-surgeon; First Lieutenant William H. Cook, assist- 
ant-surgeon. To the Thirty- third Infantry, United 
States Volunteers, headquarters Fort Sam Houston, 
Te.xas, Major B. Albert Lieberman, surgeon ; Captain W. 
E. Parker, assistant-surgeon. To the Thirty fourth In- 
fantry, United States Volunteers, headquarters Fort 
Logan, Col., Major James E. Shellenberger, surgeon; Cap- 
tain Frank W. Foxworthy, assistant-surgeon ; First Lieu- 
tenant Patrick J. McKenna, assistant-surgeon. To the 
Thirty-fifth Infantry, United States Volunteers, Vancou- 
ver Barracks, Washington, Major Julius A. Schuelke, 
surgeon; Captain Luther B. Grandy, assistant-surgeon. 
First Lieutenant John A. Metzger, assistant-surgeon. 



MEDICAL MATTERS IN HEW YORK. 

REPORT OF CONTAGIOUS DISEASES FOR THE WEEK 
ENDING JULY 8th — A CHRISTIAN SCIENTIST IN 
BELLEVUE HOSPITAL — A DEATH FROM RABIES — 
THE STRAUS MILK DEPOTS — IMMIGRANTS RE- 
JECTED ON ACCOUNT OF DISEASE — DEATH OF DR. 
F. W. FABRICIUS AT SANTIAGO — RECOVERY FROM 
TETANUS — "CHRISTIAN SCIENCE" OR "EDDVISM." 

The Board of Health makes the following report of 



ii6 



MEDICAL MATTERS IN NEW YORK. 



[Medical News 



contagious diseases in New York City for the week end- 
ing July 8, 1899: Measles, 216 cases, and 13 deaths; 
diphtheria, 191 cases, and 42 deaths; laryngeal diphtheria 
(croup), 10 cases, and 6 deaths; scarlet fever, 125 cases, 
and 7 deaths ; smallpox, 3 cases, and 1 death ; chicken 
pox, 12 cases; tuberculosis, 98 cases, and 140 deaths; 
typhoid fever, 16 cases, and 10 deaths; cerebrospinal 
meningitis, 4 deaths. 

In some inexplicable way a man who claimed to be a 
Christian Scientist, an "Eddyite" or "Divine Healer" and 
able to cure every disease afflicting the patients, got into 
Bellevue Hospital one day last week. He told the pa- 
tients that the attendant physicians at the hospital were 
their worst enemies, and were merely experimenting on 
ihem for the benefit of the higher classes. The man 
had elaborately printed cards, on the back of which were 
crosses in red, and "P. J. Durvin, 285 Bowery," also the 
announcement that he and the Savior were able to cure 
every manner of disease. Durvm succeeded in passing 
through several of the wards before he was interrupted. 
It is said that he then left the hospital by the "most di- 
rect route." The patients were all more or less excited 
over the visit. 

Charles N. O'Neil, four years of age, living at Mont- 
clair, N. J., was bitten in the face by a dog June 1st. 
ThefoUow-ing day he was taken to the Pasteur Institute in 
this city, where he was treated by inoculation. The 
crisis had been passed and recovery seemed certain, when 
the boy developed marked symptoms of rabies and died 
July i6th. 

The Nathan Straus milk depots have been opened 
at various points in the tenement-house districts and 
on the recreation-piers. Pasteurized milk and fresh 
milk cleansed by the centrifugal process is sold by the 
glass for one cent, and pure and modified Pasteurized 
milk are furnished in bottles for infants at nominal rates, 
or free to those too poor to pay. 

The medical examiners at the port of New York, dur- 
ing the month of June, 1899, examined 30,754 immi- 
grants. Of these 1 26 were rejected as suffering from 
loathsome or contagious diseases. 

Acting Assistant-surgeon Frederick W. Fabricius of 
the United States Army, formerly a practising phy- 
sician in this city, twenty-six years old, died the 
death of a hero at Santiago de Cuba on Sunday, June 
25, 1899. When yellow fever first made its appearance 
among the American troops, Dr. Fabricius, although not 
an immune, plunged into the work of life saving with such 
energy that he soon exhausted his physical powers, and 
within a week fell a victim to the dreaded disease. He 
died five days after he had been attacked by the fever. 
Dr. Fabricius was graduated from the Bellevue Hospital 
Medical College, class of 1893, and was an interne at 
Bellevue from 1894 until 1896. He was afterward con- 
nected with the Metropolitan Hospital for the Insane. 
When war began between the United States and Spain 
the young physician offered his services to the govern- 
ment, and was appointed acting assistant-surgeon in the 
army. He was first stationed at Fortress Monroe, Va. , 
and last December was transferred to Santiago de Cuba, 



where he held the position of pathologist and bacteri- 
ologist at the United States General Hospital up to the 
time of his illness. Dr. Fabricius was unmarried. He 
had a brother and an uncle living in this city. 

Joseph Reinberg, twelve years of age, one of the vic- 
tims of the Fourth of July fireworks, who had received 
serum treatment, both intracerebral and subcutaneous, 
was reported July 17th as convalescent. Some of the 
firecracker wadding which was taken from the wound in 
his hand has been sent to the laboratory of the College of 
Physicians and Surgeons for examination as to the pres- 
ence of tetanus germs. There seems to be reasonable 
grounds for the belief that the pulp from which firecrack- 
ers are manufactured is made from the dirty scraps of pa- 
per collected from the streets, and therefore supplies the 
source of tetanus infection. 

A much-advertised meeting of the Medical and Legal 
Relief Society was held at the Waldorf-Astoria on the eve- 
ning of July 13th to take steps toward devising a bill for 
presentation in the New York Legislature to restrain the 
practice of Eddyism or Christian Science. The movement 
was evidently ill-advised and improperly organized. The 
members of the society and the representatives of the med- 
ical profession were conspicuous by their absence. The 
meeting was captured by a strong representation of Eddy- 
ites, and the effort resulted in a fiasco. As Mr. W. A. Pur- 
rlngton pointed out In a recent letter to the New York Sun, 
it seems obvious that attempts at legislation in ..he matter 
should not be made ill-advisedly or without due organiza- 
tion. In confirmation of this Mr. Purrlngton narrates the 
history of an effort made in 1898 by Senator Coggeshall 
to secure the passage of a bill that would have restricted 
the practice of Eddyism. At its hearing in committee so 
many Eddyites, most of them in skirts, were present that 
adjournment was had to the Senate Chamber. Appar- 
ently no one spoke for the bill and no one of note against 
it. After the usual platitudes concerning liberty and the 
customary depreciation of medicine as an unfinished sci- 
ence, the Senator is reported to have smiled, bowed to 
the ladies, and abandoned the bantling upon Mrs. Eddy's 
doorstep as cheerfully as he took it from its parent, who- 
ever that may have been. It was another instance of an 
enthusiastic and organized few carrying their point, while 
the unorganized multitude was Indifferent and apathetic. 

Mr. Purrington's letter is so clear upon the relation of ex- 
isting law to Christian Scientists that it seems quite 
worth while to quote freely from it. He says: "No 
medical law of any State enjoins or prohibits any system 
of medical practice. No law forbidtjing the practice of 
Christian Science or any other system of treating the sick, 
no matter how foolish, has been proposed. Those who 
assert the contrary do so ignorantly or with Intent to mis- 
lead. What medical laws require, and In the opinion of 
the Supreme Court of the nation and of almost every 
State properly require, is that no person shall practice 
medicine before he has pursued a proper course of study 
and furnished some evidence that he has a fair knowledge 
of the human economy and the sciences relating thereto. 
This regulation applies to Roman Catholics, Protestants, 
and Jews. It is objected to by Christian Scientists and 



July 22, 1899] 



MEDICAL MATTERS IN PHILADELPHIA. 



117 



Spiritualists, who stoutly maintain that to require the 
same education of them as of others engaging in the 
same business is to infringe their liberty of conscience and 
right to worship in their own way, although it is undeni- 
able that when a man has once obtained a license to 
practice medicine upon proof of his scientific attainments 
he may follow any system he chooses. He may, if he 
sees fit, rely solely upon mental processes. Every phy- 
sician does largely lake into account and rely upon the 
effect of the mind upon the body, especially in certain 
classes of cases. There are few to-day who pretend that 
the high potencies of homeopathy have any medicinal ac- 
tion, and it was a realization that their effect was due to 
the patient's imagination that led Mrs. Eddy, as she says, 
into h;r own extraordinary system. But homeopathists 
admit the existence of disease. They often administer 
drugs as heroically as regular practitioners — sometimes 
more heroically. They use surgery skilfully. In fact, it 
is often difficult to differentiate them from regular physi- 
cians by their practice alone; nor was there ever a time 
when they did not claim to be called physicians. The 
Eddyites, on the other hand, although eager to dub them- 
selves 'doctors of Christian Science,' declare that they are 
not practitioners of medicine. Mrs. Eddy, as was fully 
pointed out in the North American Review for March, 
condemns not only drugs, remedies, and ins'.ruments, but 
even hygiene, exercise, and bathing. Her method of 
curing disease is first to deny its existence and then to 
argue with it as one would argue with a Congressman. 
Herein lies at once the danger of her crazy method and 
the immunity of its practitioners from punishment under 
the law of this and many other States. A druggist who 
prescribes a proprietary nostrum or so simple a remedy 
as rhubarb or chalk mixture may be convicted of a mis- 
demeanor. Our Supreme Court has so held in several 
casts. But it also has laid down in Smith z)s. Lane (24 
Hun., 632) the narrow rule that the use of drugs, medi- 
cines, or instruments is an essential element of medical 
practice, holding, in substance, that the medical law was 
intended only to protect those seeking treatment secon- 
dum ariem from false pretenders to skill in the use of 
dangerous drugs or instruments, but not to protect from 
their mistake or folly, persons who, lured by wonderful 
promises of cure, submit themselves to the treatment of 
those avowedly discarding ordinary medical methods. 
This case, expressly approved of in Ohio, Rhode Island, 
and perhaps other States, is the joy and bulwark of 
Christian Scientists. It was held to be inapplicable un- 
der the Nebraska and Illinois statutes; but from the last 
Legislature of the latter State the Eddyites are said to 
have secured a proviso, in the new medical law adopting 
its rule. 

"h will be remembered that a letter in the Sun 
of June 9th, the accuracy of which has not been denied 
to my knowledge, showed that when Mr. Carol Norton, 
Mrs. Eddy's apostle hereabouts, was asked if he would 
dare to exclude medical aid and treat severed arteries, 
fractures, strangulations, and contagious diseases by 
mental processes he twice wrote that he preferred to 
shelve the questions. It must seem startling to a layman 



that a druggist violates the medical law by prescribing 
rhubarb, while a Christian Scientist who 'thinks at' the 
severed artery of a child is exempt from the operations of 
that statute. 

"But does it follow that we are without remedy 
under existing law? It would seem not. If it can 
be demonstrated that a Christian Scientist has caused 
death by excluding proper medical or surgical treatment 
and substituting his mental processes — In such cases, for 
instance, as those submitted to Mr. Norton and 'shelved' 
by him — It ought not to be difficult to obtain a conviction 
of manslaughter, if not of murder. The societies for pre- 
vention of cruelty to children can act in the premises. 
English courts are extraordinarily lenient with fanatics, 
but although Wagstaffe escaped punishment prior to the 
enactment of the Prevention of Cruelty to Children 
statute, that law seems to have been passed in conse- 
quence of his acquittal; and recently another member of 
the 'Peculiar People,' whose child died under a similar 
treatment by anointing with oil In Apostolic fashion, was 
convicted of manslaughter. If memory serves, Mr. 
Gerry, some years ago, took from a missionary a child 
whose fractured arm the father was treating solely by 
such anointing; and the bishop forbade the parent to go 
back to his post. There is no reason vvhy Christian 
Scientists should not be compelled to report births, 
deaths, and contagious diseases under the usual penalties 
for disobedience. If they say that it is wrong to compel 
them, who do not believe in disease, to report its exist- 
ence, once more the answer is simple : Mrs. Eddy her- 
self has reported in print that her first husband. Colonel 
Glover, died of 'yellow fever,' that insidious disease. But 
after all, that which will destroy Christian Science is the 
true exposition in the reviews and dally press of Its ab- 
surdities, its vulgarities, its false pretences, as well as its 
dangers. It does not seem possible that a sane or rever- 
ent mind or one with any sense of humor could accept 
seriously the preachment of the exceedingly shrewd, but 
very ignorant and ungrammatical old lady, once of Lynn 
but now of Concord. And it is safe to say that unless 
Christian Scientists can win some temporary advantage 
by cheap martyrdom the time will come very soon when 
sane and reputable persons, many of whom now accept 
the doctrine ignorantly, will blush with shame to think 
they ever could have been disciples of Mary Moss Baker 
Glover Patterson Eddy, whose name seems to be legion." 



MEDICAL MATTERS IN PHILADELPHIA. 

A LAW TO PREVENT POLLUTION OF THE SCHUYLKILL 
RIVER — LICENSES FROM OTHER STATES DO NOT 
(JUALIFV THE HOLDER TO PRACTISE MEDICINE IN 
PENNSYLVANIA — MORE "FAITH CURE" NOTES — 
TETANUS RESULTING FROM FIREWORKS' INJURIES 
— THE BOARDOF WATER EXPERTS — DI PHTHERI A IN 
SOLDIERS' UNIFORMS — DR. CATTELL ELECTED 
PATHOLOGIST TO THE PHILADELPHIA HOSPITAL — 
APPOINTMENTS OF MEDICAL MEN BY GOVERNOR 
STONE— PERSONAL. 

At the thirty-third annual meeting of the Pennsylvania 
State Board of Health, held this week, a regulation was 
adopted for the prevention of pollution of the Schuylkill 



ii8 



MEDICAL MATTERS IN PHILADELPHIA. 



[Medical News 



River. The new regulation, which is based upon power 
recently vested in the State health authorities by an 
act of legislature, absolutely prohibits the pollution of this 
stream by deposits of excrement of all kinds, from any 
source whatsoever. Recent official investigations having 
shown the presence of widespread contamination of the 
Schuylkill by the sewage of dwellings, institutions, and man- 
ufactories situated along its banks, the importance of the 
new order can scarcely be exaggerated. The board, now 
that it possesses the power to do so, will at once begin 
the work of abating the nuisances, by rigorous enforce- 
ment of the new law; and, it is to be hoped, without fear 
or favor of either individuals or of corporations. 

Congratulations should be extended to the Pennsylvania 
State Medical Council for its recent successful efforts 
in the courts to uphold the standard of legal requirements 
for the practice of medicine in this State. In a suit 
which was decided this week by Judge Simonton, a man- 
damus was refused compelling the Medical Council to 
issue to a Dr. George A. Ludwig, a license to practise 
medicine, without the necessary qualification of examina- 
tion. The physician in question is a graduate of a Balti- 
more medical school and a licentiate of the Maryland 
Medical Examining Board, and he applied for a license in 
this State on such credentials. The license was properly 
refused, so he carried the question to the courts, evidently 
to test ihe legality of the Medical Practice act of this 
Commonwealth. Judge Simonton. in refusing to grant 
the mandamus, based his decision upon the fact that the 
medical law of Maryland, under which the petitioner was 
qualified, fails to meet the demands of the medical law 
of Pennsylvania. This decision should form a valuable 
precedent, to deter, in future, licensed physicians from 
other States where the qualifications may happen to be 
trivial, from attempting to evade the Pennsylvania law, 
by presenting such credentials in lieu of standing the 
regular examination required in this State. 

It becomes painfully monotonous to have to record, 
week after week, the far-reaching evils of the "faith -cure" 
and allied insanities in this vicinity, but once again your 
correspondent feels called upon to note still another death 
from the practise of the delusion. This time it is the case 
of a young child, now dead of scarlet fever, whose father 
not only refused to call in medical attendance for the 
little one, but even failed to report the illness to the 
health authorities of the town. The father, Jacob W. 
Gracely, by name, is reputed to trust rather to the Lord 
than to physicians for the treatment of disease, and he 
is himself following out this line of belief in his own case, 
for he is also ill. The authorities of Allenton, where this 
individual lives, have placed him under arrest, not for 
believing in the Lord, but for violating the law requiring 
the notification of contagious diseases, but sentence has 
been suspended pending the prisoner's indisposition. 

More "faith-cure" news com-s from a small borough 
in Chester County, to the effect that a petition, signed by 
most of the residents of the place, has been presented to 
the local school-director, requesting the reconsideration 
of the appointment of a school-teacher who is alleged to 
hold firmly implanted Christian Science views. It is 



stated that the teacher complained of has openly advo- 
cated the teachings of this sect, made "converts" to the 
faith, and aired her views of the question in the school- 
room. The school directors are divided about the re- 
moval, and the deadlock may have to be broken by the 
courts. 

Contrasted with New York City, where such an epidemic 
of tetanus has followed the Fourth of July, Philadelphia 
may consider herself exceedingly fortunate. This city 
has not escaped, however, as the five fatal cases of tet- 
anus from injuries by fireworks testify. In addition to 
these, there are several other cases, convalescents, or of 
mild infection. Judging from the large number of acci- 
dents suffered by Fourth of July celebrators in Philadel- 
phia, the number of tetanus cases has been few. 

The three water-experts appointed by the mayor, 
Messrs. Rudolph Hering, Samuel H. Gray and Joseph 
M. Wilson, have just visited Albany, N. Y., where they 
inspected the model 15. 000,000 gallon water-filter, con- 
sidered one of the best-constructed plants in the world. 
As yet, the experts have not advanced any definite plan 
of water-purification for this city, and their decision in 
the matter will not be arrived at until after extensive in- 
spections of water works in various parts of the country 
and until after careful consideration of every phase of 
the question. The public prints are full of all sorts of 
rumors attributed to the board of experts, but their en- 
dorsement of any method of water-supply suitable for this 
city will remain problematic until the publication of their 
official report to the mayor. 

Owing to the vigilance of the factory inspectors and 
the health authorities, a quantity of soldiers" uniforms 
ready for delivery to the Schuylkill Arsenal this week, 
were found to have been exposed to infection by diph- 
theria; the articles of clothing were immediately confis- 
cated and sent to the disinfecting-station for sterilization. 
This is the second instance of diphtheria-infected cloth- 
ing which has been reported in this city within a fort- 
night, and the detection of the danger testifies to the 
watchfulness of the factory inspectors, who made the dis- 
covery in both instances. 

At the last meeting of the Board of Charities and Cor- 
rection, held this week. Dr. Henry W. Cattell was elected 
pathologist to the Philadelphia Hospital to succeed Dr. 
John Guiteras, who recently resigned. 

Governor Stone has announced the following appoint- 
ments of medical men during the past week: Dr. J. L. 
Forwood of Chester, to be a member of the Quarantine 
Board for the port of Philadelphia, vice Dr. Ernest La 
Place, whose term expired July ist, and Drs. John H. 
Gibbon of Philadelphia and Herbert A. Arnold of Mont- 
gomery County, to be assistant surgeons of the National 
Guard of Pennsylvania, with the rank of first lieutenant, 
with assignments to the Sixth Regiment, Infantry. Gov- 
ernor Stone has also commissioned as medical officers of 
the National Guard Major Francis R. Packard, surgeon, 
and Captain R. W. Montehus, assistant-surgeon, both 
with rank from June 14. 1899; and Lieutenant Walter 
Boardman, assistant-surgeon, with rank from July 11, 
1899. 



July 22, 1899] 



SCIENTIFIC MEDICAL JOTTINGS. 



119 



Among the medical profession of this city nearly 
"everyone who is anyone" seems to have joined in the 
midsummer rush Europeward. Among the latest de- 
partures and those who expect to sail during the next few 
days may be mentioned Drs. James C. Wilson, J. Mont- 
gomery Baldy, G. Hudson Makuen, Solomon Solis- 
Cohen, Howard F. Hansell, and M. S. French. Dr. 
Henry C. Chapman, who has been abroad since early last 
spring, is expected to return the latter part of August. 

The number of deaths in Philadelphia during the week 
ending July 15th reached a total of 482 — an increase of 
47 over those of last week, and a decrease of 1 1 from 
those of the corresponding period last year. Returns of 
contagious diseases are as follows: Enteric fever, 40 
new cases, with 9 deaths ; diphtheria, 64 cases, with 1 7 
deaths; scarlet fever, 35 cases, with 2 deaths; and cere- 
brospinal meningitis, a single case, and 2 deaths. 



S Cl£N T/F/C MEDICAL JOTTINGS FROM 
AMERICAN TROPICAL COUNTRIES. 

carrion's disease. 

A DISTINCT contribution to South-American medicine is 
the recent publication of a volume on "La Maladie du 
Carrion" by a friend of the martyr scientist, whose heroic 
inoculation of himself, unfortunately with fatal result, has 
added so much to our knowledge of the disease. 

The disease has been known as long as history goes 
back in Peru. When the Spaniards under Pizarro landed 
in the country they were stricken with it. It has been 
known by many names, nearly all of them having refer- 
ence to its occurrence in Peru, or at least in the 
Andes Mountains. It has been called verruga des 
Andes and verruga Andicola, the wart of the dweller 
in the Andes; verruga de CastiUe, because of its occur- 
rence among Spaniards when first brought to European 
notice. The new name proposed for it. La Maladie du 
Carrion, seems to be a worthy tribute to the fearless 
young investigator who made the true character of the 
disease known, though his inoculation of himselt cost 
him his life. 

During the building of the railroad from Lima to Oroya 
a number of the workmen were prostrated by a fever that 
often proved fatal. It was practically aiways compli- 
cated by a cutaneous eruption resembling that of verruga 
Peruana, and it was a matter of great doubt as to 
whether two diseases coexisted. It was thought that the 
fever might be a serious form of malaria during which, 
owing to lack of resistive vitality, the verruga Peruana 
succeeded in getting a foothold. Carrion, a medical stu- 
dent, inoculated himself with material taken from one of 
the cutaneous lesions and is considered to have demon- 
strated that the fever and the eruption were symptoms 
of one and the same disease. He developed a cutane- 
ous eruption and a very high fever which proved fatal 
on the thirty-ninth day. He had the satisfaction of 
knowing before his death that he had solved the problem 
of the identity of the two diseases. 

As the disease may last for months in certain chronic 



forms it would seem that physicians on our seaboard 
should know something of it as they are liable to meet 
with examples. The eruption occurs in two forms, a 
miliary and a tubercular or, as they say in Spanish, 
mular form. The miliary form is not unlike prurigo at 
times or sudamina, though the little indurated nodules 
which are very superficial may become umbilicated and 
so resemble variola. It may be localized when it oc- 
curs on parts especially subject to irritation, as the 
face, hands, and feet, and the knees and elbows. 
Often it is universal. The tubercular form occurs as 
nodules at first to be felt rather than to be seen in or 
under the skin and later reaching good size, sometimes as 
large as a small orange. These large nodules sometimes 
retrogress but oftener form adhesions to the skin and 
break down. Fever always occurs, sometimes just after 
the eruption. The height of the fever seems to de- 
pend on the amount of the eruption. Plentiful external 
eruption relieves the system of toxins by elimination as it 
were. The nodules have been found on the serous 
membranes and in all the internal organs, even in the 
bladder and testicle, and in Peyer's patches. The fever 
is often of quotidian type, with afternoon elevations ; 
sometimes, however, it is of tertian type, and it may at 
times be very irregular, but it never fails to make its ap- 
pearance some time in the course of the disease. 

SANARELLl'S BACILLUS NOT THE CAUSE OF YEL- 
LOW FEVER. 

Dr. A. Matienzo in the Gaceta Medica, the periodical 
of the National Academy of Medicine of Mexico, Vol. 
XXXVI., No. 10, in a note on the bacteriology of yel- 
low lever gives the details of six cases of the disease in 
which he sought carefully, and with the technic advised 
by its discoverer for Sanarelli's bacillus but failed to find 
it in any one of the cases. 

In conclusion, he says: The bacillus claimed b/ Sana- 
relli as the cause of yellow fever, and whose presence 
cannot be demonstrated after repeated investigations 
such as I detail here is evidently not the true cause of the 
disease. Sanarelli himself admits that it cannot be found 
in nearly one-half the cases, and this flagrant violation of 
Koch's law of pathogeneity should be enough to con- 
demn the idea of its specific etiology for yellow fever. 
Novy, working under Roux at Paris, has shown recently 
that Sanarelli's bacillus by its add reaction with tourne- 
sol and its production of gas in glucose solution resem- 
bles the colon bacillus, though it has certain similari- 
ties with the bacillus of Eberth that seems to show that 
it belongs rather to the family of the typhoidal bacillus. 

The most important fact that speaks against its spe- 
cific pathogeneity for yellow fever is that its vitality is not 
inhibited in the least by exposure to a temperature of 
fifteen degrees below zero, and that this exposure does 
not even temporarily paralyze its germinative powers. 

Dr. Matienzo agrees finally with Novy that the germ 
of yellow fever, very probably like that of hydrophobia 
and other well-known diseases, is so small that it is be- 
yond the power of the best lenses we have at present ; th •> 
it is "in the realm of the infinitelv little." 



TRANSACTIONS OF FOREIGN SOCIETIES. 



[Medical News 



MICROBES AND THE SCENTS AND COLORS OF FLOWERS. 

According to La Nature, Dr. Domingos Freire, the 
well-known yellow-fever expert of Rio Janeiro, and whose 
inoculations with yellow- fever serum have attracted so much 
attention, claims to have found that most of the flowers 
harbor micro-organisms of various kinds. Some of these 
microbes are startlingly similar to some of the pathogenic 
varieties of bacteria. Dr. Freire expresses the opinion 
that the presence of these bacteria is not merely a passing 
mcidem in the life of the flowers but that they are inti- 
mately associated biologically with them as hosts. He 
thinks that a sort of symbiosis exists and that the color 
and scent of the flowers are really due to bacterial para- 
sites that flourish on them. He has found without 
doubt that in certain cases at least, a microbe can be cul- 
tivated from the surface of a flower, which in culture 
media reproduces the color of the flower or one very sim- 
ilar to it. He has found, for instance, a pinkish lepto- 
thrix that grows on the Rosa Rothschild which is always 
of a pink color. In the same way he has demonstrsted 
that the odors of flowers may be reproduced in cultures 
of microbes obtained from them. 

Dr. Freire considers that some at least of the bacteria 
that he finds so commonly on flowers may be pathogenic 
for man. Certain forms he has not been able to differ- 
entiate from well-known pyogenic microbes. The bacil- 
lus pyocyaneus seems to occur in connection with certain 
tints. Very often he has found on flowers certain micro- 
coccic forms resembling the ordinary' pus-cocci, which he 
considers have been deposited there from the air and 
either have been able to reproduce themselves or at least 
have retained their vitality. As they are by no means 
infrequent and as the flowers possess ample opportunities 
for the collection of floating micro-organisms from the air 
and as especially such as are grown during the winter 
months in warm living rooms, are continually in the 
midst of conditions of heat and moisture that would favor 
the multiplication of microbes. Dr. Freire advises against 
close contact with such flower? especially by delicate per- 
sons. It is this property of microbe cultivation it would 
seem, rather than any supposed noxious organic product 
that is thrown off from them that constitutes the real dan- 
ger of having flowers in living rooms. 

BACTERIA AND TOBACCO. 

An almost as surprising development of bacteriology 
is that touched on by Nuttal in the June number of the 
Contemporary Review, but in this case it is as helpful 
agents that they are found at work. Certain observa- 
tions in Cuba and Florida seem to make it clear that dur- 
ing the time that tobacco is maturing after being cut 
down there is a development in it of bacteria. It is this 
that raises the temperature of the tobacco and if it is al- 
lowed to proceed too far wHll spoil the leaf. The 
growth of these bacteria produces the characteristic 
qualities of the special form of tobacco, and in the to • 
bacco of different countries it is not so much the varieties 
m the tobacco plants themselves or the conditions of 
moisture, soil, and climate under which they have grown 
as the varieties of colonies of bacteria that develop on 



It which makes the ultimate differences in the ma- 
ture product. 

COMPARATIVE MILDNESS OF PURULENT OPHTHALMIA 
NEONATORUM IN WARM CLIMATES. 

Dr. J. S. Fernandes in the June number of the Gaceta 
Medica of the National Academy of Medicine of Mexico 
reasserts, as the result of obser\'ations and comparisons 
made during the last ten years, that the disease type of 
purulent ophthalmia (gonococcal) of the newborn is 
much milder in warm climates than it is in Europe. This 
was asserted some time ago at the Paris Society of Oph- 
thalmologists, but was received with some incredulity. 
Dr. Augustin Chacon found it to be the fact in Mexico 
and now Dr. Fernandes confirms it for Havana. In 
many cases the gonococcus was found, yet, in some of 
these patients under the ordinary treatment for catarrhal 
conjunctiWtis, they were on a fair way to recovery. The 
complications and serious sequelae were much rarer than in 
Europe. We do not know that it has ever been noted 
m temperate climates that purulent ophthalmia neona- 
torum is less virulent in the summer time, yet this 
ought to be the case if it is the temperature alone of 
warm climates that causes the difference in the types of 
the disease. Dr. Fernandes suspects that there are other 
factors at work though he is not able to designate them 
very definitely. 

TR AN S ACTIONS OF FOR E I GN SOCIETIES. 

French. 

CACODYLIC MEDICATION — PENETRATING WOUNDS OF 
THE CHEST — ANOTHER CANCER PARASITE— MOVE- 
MENT OF THE RIBS IN PLEURISY — CASTRATION FOR 
TUBERCULOSIS OF THE TESTICLE — SUTURE OF TWO 
FRACTURED CLAVICLES — TUBERCULOSIS OF THE 
SPLEEN — SYPHILITIC GLOSSITIS IN A WOMAN. 

At the Academy of Medicine, June 6th, Gautier 
said that he had used cacodylate of soda in profound 
anemia, in malarial cachexia, and in many cases of con- 
firmed tuberculosis. Although cacodylic acid contains 
543 per cent, of metallic arsenic, it is certain that the 
cacodylate of soda is not an ordinary arsenical compound. 
It causes the fever of phthisis to fall slowly but steadily, 
at the same time that it promotes assimilation and in- 
creases the patient's weight. The stomach will support 
indefinitely a daily dose of from i >^ to 3 grains and 
almost the same amounts may be administered subcu- 
taneously to an individual who cannot Lake without dis- 
turbance -j-ij of a grain in Fowler's solution. This dif- 
ference in poisonous action between organic and mineral 
arsenic is explained by the experiments of Besredka who 
found that mineral arsenic injected into the peritoneum 
or under the skin is absorbed by the leucocytes and passed 
on in an organic form to the other cells of the body, es- 
pecially those of the nervous system. If mineral arsenic 
IS injected so that it comes into immediate contact with 
the nervous centers, before it can be changed by the leu- 
cocytes, it is found that the fatal dose is only the one- 
hundredth part of the amount which is fatal if the 
drug is first changed by the leucocytes. 

The cacodylates are irritating in large doses, stimulat- 



July 22, 1899] 



TRANSACTIONS OF FOREIGN SOCIETIES. 



ing in therapeutic doses. They e.Kcite reproduction of 
the lymphoid corpuscles, especially the polynuclear ones, 
which protect us from infectious bacteria and their prod- 
ucts, and cause the rapid multiplication of the red cor- 
puscles. Cacodylic medication, therefore, appears to be 
an excellent remedy to regulate o.xidization and conse- 
quently to renew the blood and tissues. In phthisis the 
cacodylate of soda should be given hypodermically in 
doses of from '/i to J4 of a grain daily. This medica- 
tion should be continued daily for a week and then 
omitted for a week, to be resumed if the appetite begms 
to fail or the temperature to rise. 

Robin thought that cacodylic medication should not 
be classed with arsenical as the action of the former ex- 
cites, and that of the latter restrains organic changes. 

Gautier said that the restraining action of arsenic 
follows large doses. In minute doses its action is also 
an excitant one. 

At the session of June 13th Delorme, in speaking of 
the treatment of penetrating wounds of the chest, laid 
stress upon the good effects of absolute quiet, antiseptic 
dressing of the wound and, according to circumstances, 
the administration of morphin, ether, caffein, etc. On 
account of the excitement usually attendant upon a shot 
from a pistol, morphin is particularly beneficial to quiet 
the nervous condition. The patient should not be moved 
for some days. 

Artificial serum for loss of blood is a valuable restora- 
tive, but it should be injected slowly lest it cause pulmo- 
nary congestion and increased respiration, and so bring 
about fresh hemorrhage. If hemothorax threatens life, 
the chest should be opened and the hemorrhage stopped 
by ligatures or tampons. On account of the danger of 
infection from the bronchi, pneumothorax after a pene- 
trating wound of the chest demands immediate surgical 
interference. 

Lucas-Charipionniere entirely disagreed with De- 
lorme's treatment of hemothorax. In such conditions the 
additional traumatism of an operation may readily cause 
death, while apparently hopeless cases if left to them- 
selves, may recover. 

At the Academy of Sciences, May 23d, Chevalier 
said that he had isolated a fungus from cancers which 
could be cultivated in bouillon made from a cow's udder 
and in other media. The microscopic appearances of the 
molds varied greatly according to their age and the me- 
dium employed. Inoculations of the cultures into the 
skin of guinea-pigs, rabbits, and dogs produced not only 
local tumors, but secondary visceral nodules and a gen- 
eral cachexia. Microscopically the tumors resembled 
sometimes sarcoma, sometimes fibrosarcoma, sometimes 
carcinoma. In spite of these facts Chevalier hesitated 
to announce as yet that this fungus was the cause of the 
original tumors in man from which it was isolated. 

June i2th,BoucHARD and GuiLLEMiNOT reported that 
by means of the X-rays they had ascertained that in re- 
cent unilateral pleurisy, the ribs of the affected side move 
less, and are held more obliquely than on the well side. 
In chronic pleurisy and in long-standing unilateral 
phthisis, this obliquity still more increased. In persons 



so affected the range of motion of the ribs is much de- 
creased so that respiration becomes largely abdominal 
even in women. 

At the Surgical Society, May 31st, Delbet spoke of 
the advantages and disadvantages of castration in tuber- 
culosis of the testicles. In seventeen out of twenty cases 
which he had examined, the disease was limited to the 
epididymis. It followed that indiscriminate castration was 
not to be advised. On the other hand, the three cases 
showed that it is sometimes necessary. He admitted the 
favorable influence of castration upon tuberculosis of the 
seminal vesicles and prostate, but a similar good effect 
may follow an epididymectomy for tuberculosis. None 
of these reasons, therefore, warrant the removal of a 
sound testis, which will continue functionally active, if its 
vessels remain, even though its excretory duct be removed. 
Removal of both epididymes does not necessarily produce 
impotence. The best incision is an anterior one opening 
into the tunica vaginalis. The testicle can then be ex- 
amined and the diseased portions removed. 

PoiRlER said that a patient whom he had reported to 
the society as a case of cure of tuberculosis of the seminal 
vesicles still had the disease, as a recent examination 
showed. In five cases he had removed nodules from the 
epididymis only to find other nodules a few weeks later. 
Hence it is desirable to make a high incision and to in- 
spect the whole epididymis and vas deferens. Many 
times it will be found desirable to remove these structures 
in their entirety. 

At the session of June 7th, Guinard discussed two 
cases of fracture of both clavicles by direct violence. 
Pluyette, the surgeon in charge of one patient, a young 
man of twenty-two years of age, made an immediate re- 
section and suture of the left clavicle, and a month later 
the right one was treated in the same manner, as it had 
thrown out an enormous callous. The result on both 
sides was satisfactory. Guinard considered that the con- 
dition of the other patient precluded any operative effort. 
Two months after the accident, the man left the hospital 
with union of both bones, but with an enormous callous. 
He held that suture should not be performed immediately 
but should be reserved or postponed until it is plain that 
there is a defective callous or a f?lse joint. 

At the Medical Society of the Hospitals, June 2d, 
Widal described a peculiar type of tubercular enlarge- 
ment of the spleen, characterized by an especial group of 
symptoms, and to which attention has not yet been 
called. The patient in question began to suffer from 
pain in the left hypochondrium at his thirty-first year. 
Later a tumor slowly developed, which grew till it 
reached the inguinal region, and occupied the whole left 
half of the abdomen. It was hard and lobulated. The 
patient died in eight years, never having had ascites. 
There were tvi-o cardinal symptoms, however, a cyanosis, 
manifest especially in the extremities and face, and an 
increase in the red blood-cells to about 6,200,000 and of 
the white ones to 6,000. There was no modification in 
the numerical relation of the different kinds of white cor- 
puscles. At autopsy the spleen was found to measure twelve 
inches in length and to weigh over seven pounds. There 



THE AMERICAN PEDIATRIC SOCIETY. 



[MtDicAL News 



was scarcely any splenic tissue remaining, the whole or- 
gan being composed of tubercular nodules and sclerotic 
tissue. Microscopical tubercles were found in the liver, 
pancreas, and kidneys. 

Moutard-Martin saw a case of primary tubercu- 
losis of the spleen, in which there was an increase in the 
blood-globules, but no cyanosis. 

ACHARD also mentioned a case of primary splenic tu- 
berculosis. 

At the Society for Dermatology and Syphilography, 
June 8th, Nelaton said that the sole radical treatment 
of lupus is to remove it, making an incision beyond the 
diseased tissue as if for cancer. He had employed 
in a number of instances scraping and cauterization, but 
he had obtained a complete cure in only one instance, a 
case in which the lupus was upon the buttock. 

Balzer showed a female patient with a glossitis in the 
third stage of syphilis. This trouble is very rare in the 
female, only 2 out of 850 syphilitic women being so af- 
fected according to Barthelemy. 

FOURNIER said that this difference in sex is inexpli- 
cable. The tongue is best treated by injections of calo- 
mel. Sometimes the mjections will cause the lesions to 
disappear. The use of corrosive sublimate is not to be 
recommended, as it may injure the teeth. 



SOCIETY PROCEEDINGS. 



THE AM ERIC AN PEDIATRIC SOCIETY. 

Abstract of the Proceedings of the Eleventh Annual 

Meeting, Held at Deer Park, Maryland, Jutte 2y, 

28, and 2g. iSgg. 

Dr. William P. Northrup of New York, President 
of the Society, called the meeting to order at 10 a.m. 
He took for the subject of his address "The Teaching of 
Pediatrics." He said, in part: The American Pediatric 
Society is made up largely of teachers of pediatrics, and the 
discussion of the methods of teaching this subject are 
worthy of consideration at this time. We may ask, 
What place should the subject of pediatrics have in the 
curriculum? What number of lectures and what amount 
of time should be given to this subject in an undergradu- 
ate course? In answering these questions I must draw 
upon my own experience. In the whole scheme of in- 
struction we may admit the primary importance of gen- 
eral medicine, general surgery, and obstetrics, and then 
pediatrics shares with gynecology the second place. Our 
course in instruction at present includes didactic lectures, 
clinics, and section-teaching. There is a wave of senti- 
ment against didactic teaching and no doubt the reaction 
against the former complete dissertations on disease is 
justified, but the didactic lecturer has yet a function, 
which is to present to the beginner the salient points of 
a subject, to give the essentials of a subject. Certain 
diseases must, in addition, be seen clinically in order to 
understand them, and in addition to the regular clinic, 
attended by all, there should be section-teaching so that 
the student may get very near the patient, and if possible 
each student should be allowed to repeat the demonstra- 



tions. In this way gavage, lavage, lumbar puncture, 
etc., can be best taught. 

He then described what he considered the best arrange- 
ment of hospital rooms and wards for teaching purposes, 
and gave a list of diseases that should be taught en- 
tirely by the chair of pediatrics. He was enthusiastic 
about the value of a steriopticon for teaching purposes. 
In regard to the status of a teacher of pediatics he said 
that in their school the professor of pedriatics is not a 
member of the governing faculty but both he and his 
chief of clinic receive a salary. 

In the discussion which followed Dr. Rotch of Boston 
said: In the early history of Harvard University very little 
time wasgiven to the teaching of pediatrics, but the impor- 
tance of the subject has gradually become more fully recog- 
nized until it now holds the same position as any of the other 
branches of clinical medicine or surgery. There is con- 
tinuous teaching from October to June, and live exercises 
a week are given. The teaching is divided into didactic 
lectures, clinical instruction, and what we call clinical 
conferences. The ward-material is used in connection 
with that of the out-patient department. The examina- 
tion in pediatrics is compulsory. We also use the lantern 
and slides and rind this a most valuable means of instruc- 
tion. At the beginning of the course the time is devoted 
to teaching the students what is especially distinctive of 
the early years of life, and having been well grounded, 
first in what a healthy child should be, they are then 
taught about the diseases. At the clinical conferences 
one of the students reads a paper on some case which he 
has been asked to work up, and the paper is discussed 
first by the students and then by members of the staff. 
The professor of pediatrics holds a chair in the faculty on 
an equality with any other member of the faculty and re- 
ceives a salary. 

Dr. J. P. C. Griffith of Philadelphia: We are not 
as progressive in Philadelphia as they are at Harvard, 
but we are gradually recognizing the importance of pedi- 
atrics. At present pediatrics is an elective study at the 
University of Pennsylvania, but I am glad to say that I 
think most students recognize the importance of this 
branch of medicine. In teaching I follow very much the 
plan described by our president in his paper. 

Dr. Henry D. Chapin of New York: My work has 
been mostly with post graduate students, and I find 
that a large number of them are not well grounded in the 
principles of pediatrics. I think this is largely due to the 
fact that college authorities have not appreciated the im- 
portance of pediatrics and have not given it the proper 
place in the curriculum. It should not be tacked on to 
obstetrics or to gynecology, nor should it be treated as a 
specialty. It should be taught as a branch of general 
medicine. 

Dr. Blackader of Montreal: It has been my custom 
to devote my didactic lectures mainly to a consideration of 
infantile development and the different ways in which a 
disease manifests itself in the child as compared with the 
adult. The teacher in McGill University is associated 
with the chair of medicine, is not a member of the faculty 
and has no emoluments. 



July 22. 1899] 



THE AMERICAN PEDIATRIC SOCIETY. 



Dr. S. S. Adams of Washington : I think the matter 
of proper recognition does not rest so much with the col- 
leges as with the men themselves. If they insist upon 
proper recognition they will receive it. 

Dr. Cotton of Chicago : At Rush Medical College 
we have just adopted a plan by which the junior students 
are to be thoroughly drilled in the preliminaries and the 
seniors are to be given actual clinical experience. 

"The Increase of Weight in Infants Fed Artificially" 
was the title of a paper by Dr. Henry Koplik of New 
York. He said : During the past nine years I have con- 
ducted in connection with my dispensary clinic a labora- 
tory for the artificial feeding of infants and for the pur- 
poses of the present study infants below the age of nine 
months were observed, and as many collected as would 
remain under observation for a protracted period. I have 
studied, first, infants fed from birth, or nearly so, with a 
modified cow's milk ; second, infants fed with breast and 
cow's milk. The modilied milk supplied to these infants 
was in all cases the same, being composed of cow's 
milk diluted with an equal part of distilled water and with 
six per cent, of sugar of milk added. Infants below 
three months received three ounces of this mixture ; above 
this age an ounce was added for every month until eight 
ounces was reached, when full milk was administered. 
The infants were then systematically weighed. In some 
of the older children, who did not prosper on this Heub- 
ner-Hofman mixture, I increased the amount of fat. My 
patients were all taken from an ambulatory service in the 
slums. 

Tables are appended to show the gain in weight in 
these twenty-five cases, and I may say that I believe it is 
quite safe to predict that an infant, if it has the breast 
only once or twice in the course of twenty-four hours, 
will thrive on the bottle much better than on the bottle 
alone, and I am convinced that it is not advisable to de- 
prive the infant of the mother's breast, no matter how 
scant the secretion of the breast may be. It is very diffi- 
cult to decide how much cow's milk should be given 
such infants because it is impracticable to measure the 
amount of milk secreted by the breast in question. An 
observant mother and physician will soon find out, how- 
ever, how much additional milk should be given in any case. 

Dr. Rotch : While this work is very interesting I 
think it is not at all scientific. We cannot make a test 
of any method of feeding by the use of ambulatory sub- 
jects for the doctor can never tell what such children are 
getting when they are away from his observation. 

Dr. Koplik: I admit the force of this objection. I 
have not attempted to show the value of any particular 
mixture, but merely to determine how much weight a 
bottle-fed infant should be gaining if it were prospering. 

Dr. Rotch : That is exactly what you have not shown 
and what cannot be shown by this method. 

Dr. Morse: It seems to me Dr. Koplik has simply 
reported the gain in weight of a certain small number of 
infants fed on a certain mixture, and did not report the 
number or condition of those that did not thrive under 
the same circumstances, consequently the .work is with- 
out scientific value. 



Dr. Wentworth: If Dr. Koplik meant to recom- 
mend any breast milk as better than artificial feeding 
alone I shall have to take issue with him, because I be- 
lieve it is a vv'ell-known fact that careful chemical analysis 
has shown that when the mother's milk is scanty it is 
also apt to be a poor milk. 

Dr. Chapin : It seems to me, however, that clinical 
experience shows that it is better to give the mother's 
milk even though the albuminoids be high and the fats 
low than to cut it off entirely for substitute feeding. 

Dr. BlaCKADER: I am rather inclined to agree with 
the last speaker for it is no light measure 10 at once put 
a child on artificial food. 

Dr. Wentworth: I recognize the value of mixed 
feeding, and I only criticised Dr. Koplik's pomt that even 
a very scanty supply of milk added to the artificial feed- 
ing is better than artificial feeding alone. 

The next paper, on "Porencephalus. Case and Speci- 
men," was presented by Dr. George N. Acker of 
Washington. The patient was a male colored child, 
four years old, in whom the mother noticed, soon after 
birth, that the eyes had a peculiar appearance and that 
he did not move his right arm or leg. He never made 
an attempt to walk, or talk, and was quiet at all times 
except when hungry, when he would emit a peculiar 
shrill cry. The muscles were soft and flabby, with a no- 
ticeable atrophy on the right side and the right forearm 
was strongly flexed and could not be extended. During 
his stay at the hospital there were pronounced nervous 
symptoms and the temperature at one time reached 107° 
F. At the post-mortem examination, twenty-six hours 
after death, it was found that the right hemisphere 
weighed 19^^ ounces and the left 14 u ounces. The de- 
fect in development of the brain corresponded pretty 
closely to the parts supplied by the middle cerebral artery 
and seemed to be due to some change in this artery. The 
fissuration was quite atypical. 

"A Preliminary Communication on the Separation of 
Bacteria from Milk by Natural Processes" was read by 
Dr. R. G. Freeman of New York. He said : I have 
previously expressed the opinion that raw milk, even when 
the conditions of the dairy are satisfactory, cannot be 
considered safe for administration without heating be- 
cause it is likely to contain a considerable number of 
bacteria, and we cannot make sure that among these 
there may not be the organisms that produce diarrhea, 
typhoid fever, diphtheria, or other diseases. For that 
reason I desire to make a preliminary report on some 
work which, while incomplete, seems to show that the 
great bulk of bacteria which contaminate milk may sep- 
arate from it by natural processes without the use of fil- 
tration, heat or preservative agents. If milk is allowed 
to stand until the cream separates, and then if a separate 
analysis is made of the milk and of the cream it will be 
found that the cteam contains 300 times as many bac- 
teria as the milk, and with the rising of the cream about 
ninety-nine per cent, of the bacteria are removed from the 
milk. This separation may be due to the better oxygen- 
ation of the upper layers, which induces the organisms 
to rise to the surface, or it may be due to their being 



124 



THE AMERICAN PEDIATRIC SOCIETY. 



[Medical News 



carried up by the fat globules in their process of inverse 
precipitation. Should this prove to be correct we may 
be able to pasteurize or sterilize the separated cream and 
then add it again to the practically germ- free milk for ad- 
ministration as a food. 

The next paper, entitled "Sarcoma of the Cerebellum 
in a Child, Aged Four Years," was read by Dr. S. S. 
Adams of Washington, D. C. The patient was first 
taken ill in June, 1897, the prominent symptoms being 
high fever and vomiting. Under treatment she appar- 
ently recovered in about a week, but a month later she 
began to complain again of intense pain m her head and 
right arm. This was followed by weakness of the legs, 
the child frequently staggering and at times falling. She 
slept well at night and seemed to suffer principally in the 
mornings and afternoons. A second attack of fever and 
vomiting developed and she lost control of her bowels 
and bladder. At the autopsy the diagnosis of cerebellar 
tumor was verified. The brain weighed thirty- nine 
ounces. 

"Enlarged Bronchial Nodes" was the title of the ne.xt 
paper, read by Dr. J. Park West of Bellaire, Ohio. 
He said : Within a comparatively short time I have seen 
eight children in whom I have made the diagnosis of en- 
larged bronchial nodes and in every case the patient had 
come on account of the accompanying cough. In every 
case there seemed to be a more or less general involve- 
ment of the lymphatic system. Every child had enlarged 
cervical nodes. In six there were, in addition, large ax- 
illary nodes, and m five large inguinal nodes. All had 
large tonsils, two had adenoids that interfered with 
nasal respiration, and in three the spleen could be felt. It 
seems to me that the enlargement of these nodes was the 
local manifestation of a status lymphaticus. 

"Report of a Case of Transposition of the Viscera of 
the Great Vessels, with Photograph" was read by Dr. J. 
P. Crozer Griffith of Philadelphia. The patient, a 
boy eight months old, began three months previous to 
admission to the hospital to have attacks of cyanosis and 
dyspnea, lasting about twenty minutes and occurring as 
often as half a dozen times a day. On admission the child 
seemed ill and was distinctly cyanotic. A systolic mur- 
mur was heard with greatest intensity at the pulmonary 
cartilage and at the third left interspace close to the 
sternum, as well as at the aortic cartilage and the apex. 
It was not transmitted to the axilla and there was no 
thrill. The diagnosis of pulmonary stenosis, probably 
associated with a perforate septum ventriculorum was 
maJe. The child soon sickened with what appeared to 
be symptoms of pneumonia, cyanosis increased, and 
he was so weak that he was treated purely symp- 
tomatioally and the actual condition of the viscera was 
not investigated. I have here the post-mortem specimens 
which show the following peculiarities. The aorta arises 
from the right ventricle and passing upward arches 
slightly from left to right, then almost directly backward, 
over the right bronchus, and descends upon the right half 
of the vertebral column. The coronary arteries arise 
from the right ventricle. The pulmonary artery rises 
from the left ventricle to the left of and slightly posterior 



to the origin of the aorta. The liver lay chiefly to the left 
side and the spleen in the mid axillary line in the right 
hypochondrium. There are two supernumerary spleens. 

Dr. R. G. Freeman of New York then read a paper, 
entitled "Observations on Certain Abnormal Conditions 
in Livers of Infants and Children." He said: I have 
carefully studied the autopsy reports of some 500 cases 
at the New York Foundling Hospital, with reference es- 
pecially to the conditions of the liver. In this investiga- 
tion I have found that cirrhosis of the liver is very rare in 
infancy, as is also the condition of waxy liver. With re- 
gard to the condition of fatty liver I have found some 
points that quite contradict the ordinary statements given 
m the text-books, and am led to formulate the following 
conclusions: (i) Fatty livers occur very frequently in 
the infants and children that come to autopsy at the 
Foundling Hospital — about forty-one per cent, of all 
cases. (2) The condition of nutrition of the child appar- 
ently has no connection with the fatty condition of the 
liver, the condition of nourishment in the subjects having 
fatty livers averaging about the same as in the whole 
number of cases. (3) Fatty livers occur rarely in the 
chronic wasting diseases, such as marasmus, malnutri- 
tion, or rachitis and syphilis, unless such condition be 
complicated by an acute disease. (4) With tuberculosis 
fatty livers do not occur more frequently than in other 
conditions. (5) Fatty livers occur most often with acute 
meningitis, gastro- intestinal disorder, measles, and diph- 
theria. 

"A Case of Meningitis Due to the Typhoid Bacillus" 
was reported by Dr. A. H. Wentworth of Boston. 
The patient, four years of age, first seen October i, 1898, 
had always been a delicate child but had never had any 
previous illness. For six days prior to entrance into the 
hospital she had been feverish, drowsy, without appetite, 
and was said to have been delirious at times. On ad- 
mission there was considerable apathy from which she 
could be aroused without difficulty although she became 
quite irritable. The urine contained a faint trace of al- 
bumin. Its specific gravity was loi 5. The examination 
of the blood showed 12,000 leucocytes per cubic milli- 
meter. A provisional diagnosis of typhoid fever was 
made. The next day the nurse reported that twice dur- 
ing the night the child's body became rigid, the hands 
clenched and the eyes were rolled upward, this condition 
lasting about one minute each time. An examination of 
the eyes was made, but without result, and from fluid 
secured by spinal puncture no growth was obtained. The 
following day there was bulging of the right tympanic 
membrane and when paracentesis was performed there 
was an escape of air, but no fluid. Widal's test was 
negative, though the clinical symptoms were those of a 
moderately severe typhoid fever. On October 15 th a 
second blood count showed 9600 leucocytes. On the 
1 6th the child became very stupid and by evening was 
unconscious. Tonic and clonic convulsions and Cheyne- 
Stokes respiration supervened. On the following day 
strabismus appeared, and there was general rigidity of 
the muscles of the trunk and extremities, with spasms at 
intervals. Death occurred on the seventeenth day. 



July 22. 1899] 



THE AMERICAN PEDIATRIC SOCIETY. 



125 



Lumbar puncture was performed a few hours before 
death, and the spinal fluid obtained was turbid and soon 
showed a deposit of puriform material in the bottom of 
the test-tube. A careful study of this deposit by all 
methods showed a pure culture of the typhoid bacillus. 

In considering the diagnosis I would say that in favor 
of typhoid fever there is the onset, the duration of the 
disease, the character of the temperature-charts, the en- 
larged spleen, the failure to obtain evidence of the pres- 
ence of other diseases by means of physical examination, 
and the negative result of the first lumbar puncture show- 
ing the absence of meningitis at that time. As against 
the typhoid diagnosis there was the failure of the Widal 
test and the occurrence of doubtful convulsions in the 
early period of the disease. In favor of meningitis due 
to the typhoid bacillus there was the presence in the 
meninges of a purulent exudate which contained numer- 
ous typhoid bacilli, and the failure to detect the presence 
of other organisms by means of most careful bacteri- 
ologic examinations. 

"Vaccinoid " was the title of the next paper, read by 
Dr. F. Forchheimer of Cincinnati. He said: The 
subject of this paper is the peculiar manifestations of vac- 
cinia, which have usually been denominated false or spuri- 
ous vaccinia. Recently the French investigators have 
done much work to show the relation of these conditions 
to vaccinia. According to their classification by vaccin- 
oid is meant an atypical course of the lesions produced 
by the act of vaccination, and in their external manifes- 
tations they have the same relation to vaccinia that vario- 
loid has to variola. The speaker reported a number of 
cases observed in his own practice with a careful study 
of the subject and offered the following conclusions : (i) 
Vaccinoid is always modified vaccinia. (2) Vaccinoid 
protects against variola. (3) This protection is less than 
that of vaccination. (4) Vaccinoid in the majority of in- 
stances is due to faulty method, rarely to increased re- 
sistance or immunity. (5) In primary vaccinations vac- 
cinoid should always be followed by repeated attempts 
until either true vaccinia is produced, or until positive 
evidences of immunity exist. (6) In the presence of an 
epidemic of variola vaccinoid should be followed by re- 
vaccination, both in primary vaccinations as well as in 
revaccination. The more thoroughly vaccination is per- 
formed the fewer will be the cases of vaccinoid, provided 
the virus is perfect. Vaccinoid is an abortive vaccinia, 
and abortive vaccinia is not perfect vaccination. 

"Acute Articular Rheumatism in Infants under One 
Year of Age, with Report of a Case," was read by Dr. 
D. J. Milton Miller of Philadelphia. He said that 
from an extensive review of the literature upon this sub- 
ject it seems that acute articular rheumatism in infants is 
very rare. A number of cases have been reported as 
such which would not bear the test of the essential feat- 
tures of the disease as seen in adults. The patient that 
he had observed is an infant nine months old with an at- 
tack of genuine acute polyarticular rheumatism. In the 
diagnosis of such a rare condition every other possible 
cause for the joint affection must be excluded before we 
can assert that a given case is rheumatic. The points 



necessary to be established in making such a diagnosis 
are: mobility, proneness to migrate from joint to joint, 
absence of all tendency to suppuration, frequency of in- 
flammation of the cardiac serous membranes, the favor- 
able influence of the salicylates, and a family history, 
together with the absence of such affections as are apt to 
be attended by inflammation of the joints. According to 
this test only nineteen undoubted instances of acute artic- 
ular rheumatism occurring in infants under one year were 
found in the literature. 

The next paper, entitled "Urticaria of Mucous Mem- 
branes," was read by Dr. F. A. Packard of Philadel- 
phia. He said: This paper is written to suggest the 
possible frequency of the condition of internal urticaria as 
an explanation of certain cases otherwise difficult to un- 
derstand, such as the so-called "stomach cough" and 
"sore throat of indigestion." I have seen two cases of 
urticaria associated with asthma or bronchitis, and with 
the cases reported in the literature these make thirty-four 
in which the connection between the skin-lesion and the 
respiratory symptoms was quite close. The order of the 
occurrence is not uniform, and while in many cases there 
seems to be a balance between the cutaneous and respira- 
tory lesions the two systems are frequently involved at 
the same time 

"The Renal Complications of the Acute Enteric Dis- 
eases of Infancy" was the title of a paper read by Dr. 
John L. Morse of Boston. The essayist said in part: 
During the Summer of 1898 I examined the urine of 
seventy infants ill with uncomplicated diarrheal diseases. 
They were all out-patients at the Infants' Hospital and 
hence many could not be examined more than once. All 
were under two years of age, forty-seven being under one 
year. The urine was obtained by catheterization, scru- 
pulous care being taken as to cleanliness of the catheter. 
Tables showing the extent of the investigation and the 
results of the examinations are appended. I believe it 
probable that more- or less-marked degenerative changes 
occur in the kidneys in many, if not most, patients. 
These degenerative changes are due to the action of bac- 
teria or toxins, usually the latter. Inflammatory changes 
are rare. Albuminuria occurs in about fifteen per cent, 
of all cases and casts are found in sixty per cent, of these. 
The presence of albumin and casts does not justify the 
term "nephritis," and is not of bad prognostic import. 

Dr. Floyd M. Crandall of New York then read a 
report of ' 'A Case of Scurvy in an Infant Six Weeks 
Old." The patient was born October 12, 1898. The 
father was not in good health, having long suffered from 
chronic rheumatism, while the mother, who had a valvu- 
lar cardiac disease, following rheumatism, was anemic 
and did not recover from the effects of confinement for 
many weeks. The child was not strong and when seen 
in the sixth week there was a well-marked condition of 
scurvy. The child had never taken anything but breast- 
milk, which was very abundant, though thin and watery. 
So abundant was the supply that though the child nursed 
frequently it never emptied the breast and consequently 
only received "fore-milk," which contains a much small- 
er amount of fat than does the later milk. The child 



126 



THE INDIANA STATE MEDICAL SOCIETY. 



[Medical News 



was allowed to continue nursing, but pasteurized cream 
was given to make up the proper amount of fat, and the 
results were prompt and satisfactory so far as the scurvy 
was concerned, but the child subsequently died from an 
attack of pneumonia. 

Dr. Griffith: In a recent text-book I find the state- 
ment, in italics, that in scurvy occurring before the stage 
of eruption of the teeth there is no characteristic lesion 
on the gums. In the collective investigation made by 
this society last year twenty-four such cases were re- 
ported. 01 course the society did not assume the re- 
sponsibility for all of these, but I feel that certainly all the 
reporters could not have been wrong. 

"Congenital Cystic Kidneys, with Report of a Case" 
was read by Dr. E. E. Graham of Philadelphia. He 
said: I was called to see this baby about twenty minutes 
after its birth. It was well developed but distinctly cy- 
anotic, breathing feebly, and the cyanosis appeared to be 
more marked than the heart's action and feeble breathing 
should produce. The body was limp and the child could 
not be aroused. Death occurred forty-five minutes after 
birth. The autopsy made four hours later showed a normal 
heart, small areas of lung tissue containing air ; liver, 
spleen, and mesenteric glands normal, and both kidneys 
cystic. 

"A Case of Multiple Osteomyelitis in an Infant" was 
reported by Dr. T. M. Rotch of Boston. The patient 
was a female infant, one month old, with a history of a 
previous erysipelas starting from the umbilicus and run- 
ning down on the left leg. At the time seen the diagno- 
sis of cellulitis and probable osteomyelitis was made. An 
incision was made along the inner side of the tibia and an 
abscess found under the periosteum. A second abscess 
appeared at the posterior border of the deltoid. Cultures 
taken from both these abscesses showed the staphylococ- 
cus aureus. The infant died nine days later and autopsy 
showed a multiple osteomyelitis. 

The following officers were elected for the ensuing 
year: President, Dr. Henry Koplik of New York; secre- 
tary Dr. Samuel S. Adams of Washington ; treasurer. 
Dr. J. Park West of Bellaire, Ohio. 



THE INDIANA STATE MEDICAL SOCIETY. 

Abstract of the Proceedings of the Annual Meeting , 
Held at Indianapolis, Ind., "June 6 and 7, iSgg. 

The annual meeting of the Indiana State Medical So- 
ciety held at Indianapolis has been a great success. The 
attendance and esprit de corps partook of the general ac- 
tivity of the community and inclination to hustle observa- 
ble everywhere. E.\cellent papers were read and vigor- 
ously discussed, one or two of which deserve especial 
circulation, as, for instance: "Diphtheria and Antitoxin," 
by Dr. a. E. Powell of Marion, who reported an out- 
break of the disease in the orphanage of his coun ty. In 
substance he related that on January 15, 1899, a case of 
throat trouble developed in a female inmate, which was 
diagnosed as tonsillitis. There were sixty-eight children 
of all ages and both sexes in the institution at that time. 
Within the two weeks following twenty-five cases of sore 



throat occurred and in several of them microscopical ex- 
amination revealed the specific bacillus of diphtheria. The 
early cases progressed favorably and it was not thought 
necessary to use antitoxin. Gradually, however, the 
severity of attacks increasing, its use was begun in the 
case of a girl, aged six years, who developed severe 
pharyngonasal diphtheria. As she improved in the be- 
ginning under the treatment the local manifestations dis- 
appeared, but later she succumbed to paralysis of the 
heart. 

The second patient received 1000 units as an initial 
dose. This amount was repeated in twenty-four hours 
and the child recovered, although his heart was very 
weak. Three other children developed the disease in 
quick succession and were treated with like results, when 
it was determined to give an immunizing dose of the an- 
titoxin to all of those remaining unaffected. Accordingly, 
to each of thirty-eight children, 500 units was adminis- 
tered. There were no sKin eruptions in any case and no 
abscesses formed. None of those injected for immuniza- 
tion developed the disease. 

This experience led the speaker to the following con- 
clusions: 

1. When in doubt about a case of sore throat it is 
safest to call it diphtheria and treat it as such in every 
respect. 

2. Antitoxin is the most reliable remedy we have to- 
day in the treatment of diphtheria. 

3. Antitoxin proves itself most valuable when admin- 
istered early in the course of the disease and in sufficient 
quantity. 

4. Antitoxin is a positive preventive of diphtheria when 
administered to those who have been exposed to the dis- 
ease. 

In striking contrast to this paper was that by Dr. T. 
J. Griffiths of Crawfordsville, who selected the subject 
of "Hydrotherapy in the Treatment of Diphtheria." He 
took occasion to rap the antitoxin treatment, along with 
most others that have preceded it, characterizing them as 
being in many instances blind, cruel, and irrational. Af- 
ter calling attention to the rapidity of proliferation in 
childhood and the conditions necessary for the rapid de- 
velopment of germs either in or out of the body, viz., 
heat, moisture, and fertile soil, he proceeded by noting 
the fact that ice applied to the throat lowers the tempera- 
ture of the part below that at which germs can thrive and 
grow. Ice, he said, is as certainly a specific for diph- 
theria as is quinin for malarial poison ; no glandular en- 
gorgement or serous effusion ever takes place in the pres- 
ence of the cold produced by the application of ice. 
Under this treatment no septic swabbing with any 
preparation of iron becomes necessary ; no septic poison- 
ing ever can or will take place in its presence ; it is 
grateful, soothing, invigorating to the patient, and hastens 
convalescence without exhaustion. The same treatment 
is applicable in scarlet fever and in croup ; no remedy is 
equal to it in certainty and rapidity of action. He has 
seen a child with that never-to-be-forgotten whistling 
respiration, cyanotic from deficient aeration relieved in a 
few minutes by the application of a snow poultice. Cold 



JLLV 22, 1899] 



THE INDIANA STATE .MEDICAL SOCIETY. 



127 



is non-toxic, is a tonic, germicide, and febrifuge, and is 
easily procurable and regulatable by the physician. He 
cited Pepper and May as authorities on the question of 
therapeutics of cold. 

"The Clinical Features of Malaria as Seen at Camp 
Mount," by Dr. W. T. S. Dodds of Indianapolis, held 
the close attention of the assembly on account of the 
peculiarities manifested in the persons of the recently re- 
turned troops from Cuba and Puerto Rico. The speaker 
said that in these subjects malaria does not present itself 
in its characteristic forms; the surroundings and environ- 
ment have much to do in modifying the character which 
malarial manifestations assume. If the person infected 
be robust and healthy pre\-iously the greater the liability 
to a typical course of malarial fever. On the other hand, 
if he be anemic, and especially if he has had previous at- 
tacks, the course of the disease may de\nate widely from 
the ordinary and typical form ; he may or may not have 
febrile disturbance ; if fever be present it is likely to be of 
low degree and assume the typhoid form. Lawrence 
places the febrile actis'ity centers in the brain and assumes 
that as the malarial process progresses these centers be- 
come less and less sensitive to the presence of the para- 
site. 

The temperature ranges about 99' F. and the subject 
presents a picture of tuberculous infection, often grows 
worse and finally presents symptoms both grave and ob- 
scure. Slight splenic engorgement, in addition to the 
emaciation, is about all a physical examination will re- 
veal. The emaciation and irritability are progressive. 
Marked stomach and intestinal complications may inter- 
vene and the subject succumb to a fatal dysentery. 
While those who live in malarial districts may finally be- 
come immune so long as they remain in the same locality, 
if they change about they acquire as great a liability to 
disturbance as originally existed. The apathetic condition 
of the patient, the coated tongue, the pain in the head, 
back, and loins.and the enlarged spleen, in connection with 
epistaxis, closely resembles typhoid fever. In the con- 
gestive form the physical appearance does not correspond 
to the intensity of the trouble ; the pulse is slow, the 
rhythm disturbed, and valvular murmurs are often audi- 
ble; the patient is listless, pale, and exhausted; the ex- 
tremities are cold and irresponsive to local heat or other 
applications and the case is alarming. 

That typhoid fever may be complicated by malaria, and 
x'ice versa, is an accepted fact; the two diseases may be 
associated together and their symptoms, each distinctive, 
be plainly indicated by the clinical features of each. 
Other complications, such as pneumonia, enteritis, and 
acute rheumatism, may occur. 

The treatment may appropriately be divided into 3 
classes: (i) Complete rest; (2) specific medication ; (3) 
treatment of complications. In the chronic form a pill 
containing strychnin, iron, and arsenic forms a good ad- 
juvant to hydrochlorate of quinin, which should be fol- 
lowed by tonics, careful diet, and exercise in the open 
air. 

"The Hematozoon of Malaria" formed a fitting subject 
to follow the foregoing paper, and its microscopical ap- 



pearances were fully described by Dr. Theodore Pot- 
ter of Indianapolis. 

Dr. F. B. Thompson of La Fayette presented a paper 
on ' "Leucemia. " He said that the disease is character- 
ized by the persistent and rapid increase of the propor- 
tionate number of white blood-corpuscles, together with 
enlargement of the spleen and the lymphatic glands. It 
is uncommon among children ; men are more liable to it 
than women, in the proportion of two to one. While 
heredity does seem to exert a great influance upon its oc- 
currence, still there seems to be a condition of tem- 
perament or cachexia which is an important factor, 
especially so in some families. In all well-marked cases 
the skin presents the pale, waxy appearance of de- 
cided anemia ; occasionally the tendency to exuberant de- 
posit of pigment is well marked, giving the bronzed ap- 
pearance of Addison's disease. With emaciation well 
marked the extremities may be edematous, or general 
anasarca or ascites may be present. Not known to he 
due to specific toxic elements the symptoms are those of 
an indolent septicemia. Insidious in its beginning the 
opportunity to examine the blood is not generally pre- 
sented until the disease is well established. The chief 
element found to exist on examination of the blood is in 
the superabundance of myelocytes derived from the bone- 
marrow. Assuming the possibility of suppuration of the 
blood it is not difficult to understand why the leucocytes 
of the blood are so enormously increased. The post- 
mortem appearances of the spleen, lymphatic glands, 
liver, and kidnej-s are explained when regarded as con- 
cerned in the filtration of fluids and elimination of effete 
and toxic substances. 

In its treatment arsenic stands almost alone, doubtless 
on account of its ability to check putrefaction and tissue 
metamorphosis. Ouinin in large doses has been em- 
ployed, but when long continued, 3 grains, four times a 
day will accomplish all that can be reasonably expected 
of it as a remedy. Oil of eucalyptus, which has been so 
highly recommended, the speaker has found of little 
ser\ice. It would appear to be essentially a septic dis- 
ease and dependent upon a toxic agent for its causation. 
Primarily a disease of the blood, the glandular involve- 
ment occurs as a natural consequence. 

Dr. L. J. WiLLlEN then read a paper on "Thyosan- 
amin as a Resolvent for Scar-structure, Rendering It 
Pliable No Matter Where Situated." Derived as an ex- 
tract from the oil of mustard by the addition of three or 
four times it weight of ammonia it forms colorless rhom- 
bic cr)-stals having a garlic odor and verj- bitter taste. It 
produces both diuresis and diaphoresis in doses of from 4 
to 8 grains, three or four times a week. It should 
not be administered oftener than once Jaily. It has been 
injected in doses as high as 2 drams into carcinomatous 
tumors without any stomach distress and without appre- 
ciable good effect upon the malignant growth. It has 
been recommended in cases of keloid, lupus, enlarged and 
tubercular lymphatic glands of the neck, sarcoma, 
fibroids, and syphilis, its effects in cases of syphilis 
were manifested in the following case: J. G., aged fifty- 
six years, of good family history, given to the free use of 



128 



THERAPEUTIC HINTS. 



[Medical News 



alcoholic stimulants, contracted some years ago a specific 
disease. Height 6 feet, weight 200 pounds, in 1896. He 
complained of vertigo, double vision, dizziness, and ten- 
dency to fall forward when walking. Numbness of the 
tongue and aphasia coexisted. The left side of the body 
became weak and' was followed by cephalagia. Placed 
under a strong course of iodids and mercurials without 
any satisfactory results he repaired to the Hot Springs, 
returning in six weeks without any beneficial results. He 
consulted two prominent physicians in St. Louis and then 
went to Chicago for the same purpose. All agreed that 
he had a cerebral tumor. Confusion of ideas and im- 
paired memory, diplopia, divergent strabismus, dilated 
pupils, vascular sclerotics, aphasia, numbness of the 
tongue, dysphagia, loss of strength and mobility of the 
left arm and leg, and persistent pain in the occipital re- 
gion extending to the eyes and preventing sleep were 
marked at this time. He was given 15 minims of a 15- 
per-cent. solution of thyosanamin in equal parts of water 
and alcohol, hypodermically, three times a week. Four 
months having elapsed he is to-day regarded as a well 
man and able to attend to his business. Other cases of 
the same character, treated in the same manner, showing 
equal improvement, were reported. The good effects of 
the drug have been manifested even in cases of tuber- 
culosis. 



REVIEWS. 



Legal Decisions, Medic.'\l. By W. A. Purring- 
TON, of the New York Bar. Counsel of the New York 
State Dental Society ; Lecturer on Medical and Dental 
Jurisprudence in the New York College of Dentistry, 
etc. New York: E. B. Treat and Co., 1899. 

This is a booklet of 105 pages, most of which is de- 
voted to the citation of decisions in 131 cases at law, in- 
volving suits by, or against, physicians and dentists. 
These citations are from advance sheets of the Inter- 
national Medical Annual. The decisions are interest- 
ing to peruse but their compilation is of more value to 
lawyers than to physicians. The work contains a brief 
introductory article on the justification of State Examin- 
ing Boards and medical laws and the means of en- 
forcing these laws. To these are added "A Brief for 
the Prosecution of Unlicensed Practitioners," and a 
reprint from the Mew York Medical Record, of the 
author's article on "Manslaughter, Christian Science, 
and the Law." 

Chemistry: General, Medical, and Pharmaceut- 
ical. Including the Chemistry of the United States 
Pharmacopoeia. A manual of the Science of Chemistry, 
and its applications in Medicine and Surgery. By 
John Attfield, F.R.S. Sixteenth edition. Phila- 
delphia and New York: Lea Brothers & Co., 1899. 

Again we find a new edition of this most comprehen- 
sive manual, the fifth edition to appear within the short 
space of ten years. It is hardly necessary to mention 
that all the newest discoveries and theories are embodied 



in this edition, and that the book presents the science of 
chemistry in a most lucid manner to the medical student 
and practitioner. Toxicology, general chemistry, analysis 
of physiological as well as of other materials are 
discussed, and the book presents a most complete 
treatise on this vast subject. It is a work fit as well for 
the student as for those in search of a good reference 
book. 

It is most 'gratifying to notice that the metric system 
has been given the attention it merits. A complete index 
occupying sixty- three pages and embracing over ten thou- 
sand references greatly enhances the value of the book. 
Eighty-eight illustrations serve to explain the carefully com- 
piled text. The author is thoroughly an courant m all 
the details of interest and embodies in his te.xt all of the 
latest developments of chemical principles and the latest 
applications of chemistry to medicine and pharmacy. 



THERAPEUTIC HINTS. 



For Irritating Cough of Phthisis. — When not accompanied 
by much expectoration the following mixture is recom- 
mended: 

5 



Codeinae 


gr. iv 


Ac. hydrochlor. dil. 


3ss 


Spts. chloroformi 


3 iss 


Syr. limonis 


• • 2i 


Aq. dest. 


. q.s.ad. |iv. 



M. Ft. emulsio. Sig. One teaspoonful at short inter- 
vals when cough is troublesome. — Murrell. 

For Catarrhal Affections Following Measles and Whooping- 
Cough. — Hock advises the employment of creosote, pre- 
scribing as follows: 



B 



Creosoti 
Saccharin! 
01. morrhuje 



m. XV 

gr. 3^ 

From 2 teaspoonfuls to 



M. Ft. emulsio. Sig. 
tablespoonfuls a day. 

An Analgesic Lotion. — 

IJ Atropinee sulphat. 
Morphinas sulphat. 
Ac. oleici pur. .... 

M. Sig. For inunction at painful spot, 
cotton and rubber tissue. 



gr. u 
gr. x 

Cover with 



Preservation of Solutions of Cocain. — Jonas of Brussels 
has experimented with solutions of cocain in distilled 
water, with and without the addition of various preserva- 
tive agents, such as boric acid, glycerin, carbolic acid, 
etc., in different strengths. He finds the following so- 
lutions to remain permanently clear and unchanged : 

1. Cocain hydrochlor. ... gr. iv 
Ac. carbolici cryst. . . . gr. J^ 
Aq. dest 3 iiss. 

M. 

2. Cocain hydrochlor. . . . gr. iv 
Ac. salicylici . . . . gr. >& 
Aq. dest. ..... 3 iiss. 



THE MEDICAL NEWS. 

A WEEKLY JOURNAL OF MEDICAL SCIENCE. 



Vol. LXXV. 



New York, Saturday, July 29, 1899. 



No. 



ORIGINAL ARTICLES. 



CONSTIPATION CONSIDERED FROM THE 
STANDPOINT OF THE P R C T LO G I S T.' 

By A. B. COOKE, M.D., 

OF NASHVILLE, TENN.; 

PROFESSOR OF ANATOMY AND CLINICAL LECTURER ON DISEASES 

OF THE RECTUM IN THE MEDICAL DEPARTMENT OF THE 

UNIVERSITY OF NASHVILLE. 

It has occurred to me that a subject as trite and 
homely as constipation should not be approached in 
this presence without an introductory word of apology 
and explanation. I have not presumed to think 
that I have anything particularly new to offer; even 
to the furthest details the subject has been canvassed 
by other and abler writers. But in spite of its vol- 
ume this portion of our literature has impressed Viie 
chiefly by reason of the vagueness of conception and 
indefiniteness of expression which characterize it. 
If I shall be able to contribute anything to a clearer 
and more systematic view of the subject my purpose 
will be fully accomplished. 

It is more than unfortunate that confusion should 
exist in reference to this affection. From the stand- 
point of frequency no pathologic condition in the 
whole range of human ailments occupies so conspic- 
uous a position: and from the standpoint of the 
rectal surgeon none is of such fundamental and far- 
reaching importance. Yet strange to say, judging 
from their published works, more than one of our 
most distinguished modern specialists have regarded 
it only of sufficient moment to be accorded casual 
mention in the discussion of diseases directly trace- 
able to it. This to me is an anomalous position. 
It is scarcely conceivable that a proctologist could 
fail to realize the importance of the subject. Nor is 
it possible that there could be a reasonable question 
as to its lalling properly within his province. To 
one without the fold the inference might not seem 
wholly unjustifiable that at least one specialty in the 
great brotherhood of medicine thinks less of preven- 
tion than of cure. 

Broadly speaking, constipation is a disease in 
which, either directly or indirectly, the entire or- 
ganism is implicated. It would manifestly be im- 
possible, therefore, to attempt its consideration in 
all its phases; nor, indeed, is it desirable to do so. 
But the subject as set forth in our title presents a 

* Read at the first annual meeting; of the American Proctologic 
Society, held at Columbus, Ohio, June 7, iSgg. 



less hopeless undertaking and will, I trust, permit 
the development of practical, underlying principles 
both in essay and discussion. 

In order to gain an intelligent comprehension of 
our subject, several preliminary items seem to me 
worthy a word of mention. In the first place much 
of the confusion in reference to constipation douLt- 
less springs from lack of definite idea as to what the 
term means. Neither hard stools, nor dry stools, 
nor other kind of stools constitutes the disease. 
These expressions are merely descriptive of ph}sical 
properties, and costiveness embraces them all. Con- 
stipation is something other and more. Correctly 
speaking, it is the condition of which costiveness i5 
merely a symptom. Costiveness is not necessarily 
a disease, constipation always is, and, though usually 
associated, the former may exist without the latter. 
Again, constipation is a relative term. The line 
between the physiologic and the pathologic is 
not clearly drawn, and remarkable differences in in- 
dividual habits may not be incompatible with ordi- 
nary health. With one person two movements of 
the bowels a day may be the normal; with another 
one in two days. And cases are on record by re- 
liable observers in which not only days but weeks 
and even months elapsed without an evacuation and 
still the patients lived and flourished. So that 
neither the character of the stools nor the intervals 
between them can be properly regarded distinctive 
of the disease. 

What, then, is constipation? The definitions 
given by the lexicographers lack that precision w hich 
should proceed from clear-cut ideas on the subject. 
In all I have consulted costiveness and infre- 
quency of passages are employed as synonymous 
terms. If my conception of the disease is the true 
one, constipation may be broadly defined as a 
diseased condition of the alimetitary canal character- 
ized by a modification of function which results in the 
pathologic retention of fecal matter. With this defi- 
nition for a foundation let us take a brief glance at 
the general subject, with reference especially to 
etiology. The causes of constipation may be con- 
veniently arranged under separate headings, though 
it is to be understood that several, or possibly all, 
may be operative in any given case. 

First. Causes springing from the violation of hy- 
gienic law. Under this head would come errors of 
diet and improper habits of life, to one or both of 



CONSTIPATION. 



[MtuiCAL News 



which sources, without a doubt, a large proportion 
of all cases may be traced. Chiefly notable in re- 
gard to diet are the two opposite extremes of habitu- 
ally consuming food which leaves too much or too 
little residue. Evil results equally from both. Per- 
istalsis is largely dependent on the mechanical irri- 
tation of the bowel contents. In the one case this 
would be interfered with by over-distention from 
the excessive accumulation of refuse material; in 
the other the requisite amount would be lacking. 
Many articles of diet have in themselves a consti- 
pating tendency. This applies more particularly, 
perhaps, to beverages of which tea and alcoholics 
are familiar examples. 

In reference to habits of life, much of the greatest 
practical importance might be said. The signifi- 
x;ance of this factor in the production of constipation 
can scarcely be estimated. Yet it is a very open 
question whether it is fully appreciatsd even by the 
profession. The expression of the old physician to 
the effect that if his bowels moved naturally in the 
morning he felt sure he would not die that day, con- 
tains the germ of a profound truth. In the hurry 
and turmoil of modern life, particularly in the large 
centers, the attention to this function is made a 
matter of convenience and disease is the harvest of 
neglect. 

Second. Defective innervation. This expresses 
itself either in (a) atonicity of the muscular coats-of 
the intestines resulting in impairment of peristalsis; 
or (/') in decreased secretion. These conditions 
usually coexist and may be primary or consecutive. 
If the former, the constipation develops because of 
them. If the latter, they develoj) because of the 
already existing disease. The largest group of cases 
exemplifying these conditions is probably to be 
found in those of sedentary habits. The explana- 
tion is obvious. Paralysis is responsible for a 
smaller but more hopeless class of cases. In the first - 
mentioned class the origin of the trouble is purely 
functional, in the latter organic, yet the phenomena 
presented are identical in nature and the pathology 
involved different only in degree. Though men- 
tioned as a separate cause, and rightly so, it is evi- 
dent that defective innervation may be merely an 
effect of other causes. In fact, however brought 
about, it is a condition which may be said to exist 
to some extent in practically every case. 

Third. Closely allied to the preceding, but en- 
titled to separate classification, is the sluggishness of 
bowel function, often amounting to true constipa- 
tion, met with in many diseased and debilitated 
states of the general health. Of these, anemia, lax- 
ness of the abdominal walls, obesity, diabetes, and 
great bodily weakness from any cause may be cited. 



Fourth. A more obvious and familiar cause of 
constipation consists in the habitual use of purgative 
medicines. The pernicious effect of this practice 
requires no explanation nor emphasis. Yet its prev- 
alence, already alarmingly widespread, is increasing 
at a rate which bids fair soon to make it universal. 
Fostered and encouraged by conscienceless adver- 
tisers, it belongs to the large and growing class of 
evils for which a venal press is responsible and for 
the suppression of which active measures are 
urgently demanded. Full redress is hardly possible 
short of legislative enactment. But the medical 
profession, by recognizing its duty and aggressively 
facing it could accomplish much. Bringing the 
issue nearer home, the proctologist, from the nature 
of his calling, is confronted by an obligation even 
greater. And that spirit of broad philanthropy 
which is the mark of the true physician demands of 
him all the labor and all the sacrifice that would be 
entailed by active warfare against this evil. 

Fifth. Mechanical obstruction. This may occur 
at 'any point in the intestinal tract and vary widely 
both in pathology and degree. Though constipation 
is usually present, obstipation is the term more exactly 
descriptive of the resulting condition. Of the many 
causes operative under this head I stop for a word 
of comment upon only one. That true valves are 
present in the normal rectum modern investigation 
has left little room to doubt. But their significance 
as factors in the production of disease is only now 
being satisfactorily demonstrated. The ingenious 
methods employed and brilliant results obtained by 
Martin of Cleveland, in work along this line cannot 
fail to be convincing to those acquainted with them. 
Obstipation and hypertrophied valves are terms with 
which he has made us familiar. I have associated 
them in this connection in order to impress their 
relation and emphasize a fact. Other causes of me- 
chanical obstruction, malformations, stricture, etc., 
readily suggest themselves, but must be passed with 
the mere allusion. 

Sixth. Finally, in reference to etiology, I merely 
mention painful affections of the anus. This cause 
will be elaborated in the context. 

Now to come to questions more immediately con- 
cerned in our present purpose. From the point of 
view of the proctologist this subject is of peculiar 
interest. The relations between constipation and 
diseases of the rectum are not only intimate but 
especially noteworthy in that either may be cause, 
effect, or both with reference to the other. I know 
of no other conditions in which such relationship is 
so clearly marked and so frequently manifest. With 
respect to rectal diseases, it is a rule to which there 
are no exceptions that every lesion in the entire 



July 29 11*99] 



CONSTIPATION. 



category may either be caused or seriously modified 
by constipation. With respect to constipation, 
though perhaps not so generally recognized, it is 
clearly demonstrable that rectal disease often stands 
to it in the light of causative factor. And either 
■effect, once established, reacts powerfully and posi- 
tively in intensifying the very condition which gave 
rise to it. 

Considering constipation first in the active or 
causal role, the propositions stated are easy of veri- 
fication. That venous congestion is the great un- 
derlying factor in the production of rectal diseases 
those who have given serious thought to the question 
will require no proof. The anatomical position 
and structure of the rectum, together with its pecu- 
liar function, render this to a greater or less extent its 
normal condition. Constipation augments it. A 
collection of feces in the colon or sigmoid acts as an 
impediment to the return blood current; and the 
■dislodgment and extrusion of such accumulation, re- 
quiring as it does the cooperation of the powerful 
abdominal muscles, must result in converting passive 
into very active congestion, at the same time fur- 
nishing ready means for the infliction of traumatism. 
If the fecal mass, itself normally of firm consistence 
and more or less nodulated, contains a projecting 
foreign body, injury must attend its passage. Fis- 
sure, hemorrhoids, prolapsus, proctitis, ulceration, 
abscess and fistula are the more conspicuous lesions 
•which may be traced directly to constipation and its 
coincident phenomena. 

The present unsettled state of our knowledge as 
to the etiology of malignant growths permits no 
definite assertion in this connection. But discrimi- 
nating observation with reference to their favorite 
sites justifies the assumption that mechanical irrita- 
tion is a factor both constant and weighty. Statis- 
tics show that some 3 per cent, of all cases of cancer 
are located in the rectum. If friction may be 
admitted as a causative agency, the function of this 
organ, particularly when it has to do with costive 
■stools, would render it an ideal situation for the de- 
velopment of this disease and the wonder is that the 
proportion is not even greater. To place malignant 
growths, therefore, in the list of rectal diseases for 
which constipation is, in a sense at least, responsible 
seems to be entirely in keeping with the most ad- 
vanced thought upon the subject. The analogous 
nature of the gross lesions resulting from syphilitic 
and tubercular deposits in this locality would warrant 
a. similar deduction in regard to them. But, attrac- 
tive though the question is, it must be passed with 
these f»w comments. 

Turning now to rectal diseases as a cause of con- 
stipation, two considerations under this head are 



worthy of special note. The first is pain. In those 
lesions situated about the extremity of the rectum 
pain is practically always a prominent symptom, 
and the passage of a stool of even normal size and 
consistence is an event contemplated with reluct- 
ance and dread. Remembering that defecation is 
in large measure a voluntary process, this is an item 
of greater import than might at first sight appear; 
and, while applicable, perhaps, with special force to 
children, so long as human nature shrinks from suf- 
fering, painful affections of the rectum and anus 
must be recognized in the etiology of this disease. 

The second consideration is the influence of the 
reflexes from rectal lesions in the production of con- 
stipation. Here we enter upon less certain ground. 
Much is surmised, but very little really known 
about reflexes. Theories innumerable have been 
and are being advanced until it almost seems that 
every phenomenon not otherwise explicable is to be 
laid at their door. This tendency has worked to 
the disrepute of an etiological element which, though 
little understood, is yet both potent and pronounced. 
General discussion of the subject could scarcely be 
undertaken within the proper limits of a separate 
paper. But a few practical remarks with regard to 
the mechanism and manifestations of rectal reflexes 
seem absolutely necessary to elucidation of the idea 
before us. 

The pouch of the rectum derives its chief nerve 
supply from the sympathetic system through the 
pelvic plexuses; the portion embraced by the sphinc- 
ter muscles and the tissues of the anus almost en- 
tirely from the cerebrospinal system through the 
fourth sacral and internal pudic nerves. The former 
system, presiding over the functions of organic life, 
has to do largely with secretion and involuntary 
motion; the latter with the functions of animal life, 
sensation and voluntary motion. Whether the same 
is true of other localities or not. my observation has 
convinced me that rectal reflexes conform to at least 
one general rule, namely, that the reflex is expressed 
through the same system as that involved at the 
point of origin; in other words, that there is no 
transference of nerve impulse from sympathetic to 
cerebrospinal, and vice versa. So that a reflex origi- 
nating in the sympathetic area, if referred to the in- 
testinal tract, would express itself either in stimula- 
tion of the secretory apparatus or in increased 
peristalsis. Laxness would be the natural conse- 
quence. 

On the other hand, a reflex originating in exposure 
or irritation of a nerve-fiber in the anal canal would 
manifest itself either in pathologic sensation, /. f., 
pain, or in stimulation of a voluntary muscle. The 
latter is the point to which I would call special at- 



132 



CONSTIPATION. 



[Medical News 



tention. Any lesion of the terminal portion of the 
bowel, such, for instance, as a fissure or inflamed 
hemorrhoids, supplies the occasion of the reflex and 
the external sphincter is generally the muscle upon 
which it expends itself The effect, if long con- 
tinued, is irritability and hypertrophy of that muscle. 
When this occurs a mechanical impediment to defe- 
cation has been established and a condition of cos- 
tiveness eventually merging into true constipation 
ensues. 

Another cause for this condition of the sphincter 
and one more frequently in evidence, is neglect. 
When in response to peristalsis the fecal matter 
leaves the sigmoid and descends into the rectum a 
certain amount of irritation is excited by its presence 
and desire to go to stool is felt. The only barriers 
to immediate passage are the sphincter muscles by 
means of which Nature and the will operate to the 
welfare of the individual and in the interest of society. 
If the inclination is resisted, the feces are returned 
to their normal receptacle in the sigmoid flexure and 
the desire passes off not to return, most probably, 
for twenty-four hours. But as the accumulation in- 
creases from day to day reverse peristalsis does its 
work less perfectly and a portion of the feces remains 
in the rectum, where it becomes dry and hard from 
the absorption of its liquid contents and, impinging 
upon the delicate and sensitive mucosa covering the 
sphincters, excites these muscles to a state of chronic 
reflex contraction. In this way, just as from pain 
ful lesions of the anus, a condition ot irritability and 
hypertrophy is produced. This is a cause of con- 
stipation which I am persuaded is not duly appre- 
ciated. Neglect, costiveness, hypertrophied sphinc- 
ter, constipation is a sequence of events which 
obtains, doubtless, in many cases. And intelligent 
working comprehension of the subject requires that 
the process be recognized and each factor taken 
into account. 

Before leaving the reflexes, as pertinent to the 
subject, I mention without comment the unique and 
rather remarkable experience of a prominent Nash- 
ville physician who has reported a number of cases 
of chronic constipation due to eye-strain and re- 
lieved by properly adjusted lenses. 

The symptoms and diagnosis of constipation need 
no discussion before this body. One point, how- 
ever, will bear mention lor the sake of the emphasis 
it merits. Causes outside the rectum may beyond 
question be productive of the disease. But the 
effects of the disease itself are often such as to cloud 
its etiology by simulating other affections. Thus, 
auto-infection is probably in many cases responsible 
for the hepatic derangement, debility, defective in- 
nervation, etc., to which the constipation is credited. 



Therefore, the position cannot be considered an ex- 
treme one that this class of cases should without ex- 
ception be subjected to thorough rectal examination. 

The treatment of constipation might well afford 
the theme for a separate essay. Here I cannot hope 
to do more than indicate principles. Considering 
first the general subject, the essentials may be very 
concisely stated: If the diet is at fault, correct it. 
If the habits of life are improper, let them be modi- 
fied. When these fundamentals have received at- 
tention medication may be thought of. Purgatives 
naturally suggest themselves first in this connection. 
Their proper field of application is a very limited 
one. It may be tersely stated: In the beginning to 
relieve the costive condition; afterward only when 
necessary for the same purpose. It is always to be 
borne in mind that purgatives as a class have proper 
reference only to the symptom, costiveness. 

When the cause can be traced to defective inner- 
vation two principal indications are to be met in 
the treatment: First, reestablishment of the intes- 
tinal secretions; second, restoration of the muscular 
tone. For these purposes a great variety of thera- 
peutic agents are at command. Wisely selected 
medicines are useful but not to be exclusively relied 
upon. In conjunction with them the various non- 
medicinal agencies, such as methodical exercise, 
massage, and electricity are to be borne in mind 
and employed as indicated. Of course the general 
health will be looked after by the astute physician 
and any dyscrasia or cachexia receive due attention. 

In the treatment of constipation resulting from 
rectal diseases, we have as the first indication, re- 
moval of the cause. But I wish especially to em- 
phasize that this will not often be effective unless at 
the same time dilatation of the sphincters is prac- 
tised. In no other way can the irritability and hyper- 
trophy nearly always present be overcome. And, 
if this condition is not overcome, no line of treat- 
ment, however scientific and however faithfully 
applied, is likely to prove of more than temporary 
benefit. Fortunately, in the modern treatment of 
most rectal lesions dilatation, incidental or by de- 
sign, is a routine preliminary; and to this fact un- 
questionably the great and lasting relief of the con- 
stipation which all of us have observed following 
operations, is in large measure attributable. 

In conclusion, I wish to state my conviction that 
in a proportion of cases so large that I shall not 
venture to name it, constipation either originates in 
or is maintained by causes located in the distal ten 
inches of the intestinal tract. If I am correct in 
this, the notorious inadequacy of ordinary treatment 
is at once accounted for, and the duty of the proc- 
tologist in the premises becomes obvious. 



July 29 1899] 



HEADACHE AND INTRANASAL DISEASE. 



133 



ASTHENOPIC SYMPTOMS AND HEADACHE 

CAUSED BY THE MORE COMMON FORMS 

OF INTRANASAL D/SEASE.' 

By CAROLUS M. COBB, M.D., 

OF LYNN, MASS.; 
LARYNGOLOGIST TO THE LYNX HOSPITAL. 

He..\d.-\che, from whatever cause it may arise, is 
one of the most frequent complaints with which the 
ph3sician has to deal. It would certainly seem that 
more people suffer from this disease than formerly, 
or that they are less willing to bear the pain. The 
amount of headache medicine sold by druggists is 
something enormous, and the number of pairs of 
glasses worn to relieve headache is past finding out. 
Still the number of patients who suffer from this pain 
is steadily on the increase, and one patient relieved 
by any procedure brings many others, some of whom 
are relieved while others are not. Of the many 
causes which may produce the pain we have been in- 
clined to think refractive errors the chief This 
belief has arisen in part because our attention has 
been so often called to the part that such errors play 
in the production of headache, and in part by the 
brilliant cures that have been accomplished by the 
wearing of glasses. We have come almost to be- 
lieve that all headaches as well as most other nervous 
diseases are caused by errors of refraction or mus- 
cular unbalance. The brilliant results I do not deny 
and I have had some as miraculous as any, but I do 
believe that the patients who can be relieved of pain 
or other obscure nervous symptoms by the glasses 
that are often prescribed need to have their nervous 
system reconstructed from the foundation. That we 
often overlook other causes in our zeal to find some 
ocular error which might produce the pain no one 
will deny, and I wish to call your attention to a few 
cases in which intranasal disease so closely simulated 
eye disease as to be very misleading. These cases 
illustrate the effect of the more common forms of 
intranasal diseases exclusi\e of diseases of the ac- 
cessory sinuses. 

Case I. — Mrs. D., aged thirty-five years, con- 
sulted me in May, 1894. Her family history was 
good and the patient was well nourished and looked 
to be in good health. She complained of pain in 
the eyes and across the forehead, worse after using 
the eyes for near work. She was firmly convinced 
that the headache was due to the eyes. Tests showed 
vision in each eye to be normal. Muscular tests 
showed 6° manifest exophoria. She also had chronic 
hypertrophic rhinitis. The lower turbinates were 
considerably enlarged, but did not touch the sep- 
tum. 

She was anxious to have glasses as she was about 
to make her annual visit to her old home and she 

' Read before the Section on Laryngology of the American 
Medical Association at Columbus, Ohio, June 8, iSgg. 



always suffered greatly during the railway journey of 
500 miles. One statement that she made at her first 
visit was rather puzzling at the time, namely, that 
she suffered very much in making the journey out, 
but that on her return, six or eight weeks later, she 
was nearly free from discomfort. I satisfied both 
myself and my patient by supposing that the pro- 
longed rest which she had enjoyed in the country 
had caused the change for the better. Prisms of 
2° before each eye were ordered and on her return 
she reported that the glasses gave great relief during 
the first two or three weeks, but that latterly she had 
been unable to wear them at all. On examination 
the exophoria w^as found to have disappeared, and as 
she then did not need glasses she was advised to 
wear none. 

This was in August, 1894. In November of the 
same year she called on me again, complaining of 
all the old symptoms. I then advised her to have 
the chronic rhinitis treated as the nasal condition 
was much worse than when I saw her in August. She 
came a few times for treatment and then ceased her 
visits and I did not see her again for two years. On 
her return in 1S96 she had a long story to tell, the 
principal points being that she had given up the 
treatment of the chronic rhinitis by the advice of 
her family physician, who assured her that it could 
not be cured, and that her headaches were caused 
by cervical catarrh, which could be cured. I asked 
her if the cervical catarrh had been cured and she 
promptly and emphatically replied "no." She had 
consulted two other oculists and they had both ad- 
vised partial tenotomy of the external recti. She 
had discovered that her eyes ga\e her trouble only 
in the fall and spring, during the period when her 
chronic rhinitis was worse and she was practically 
free from headache during the rest of the year. She 
is still in the same condition as she felt that she 
could not afford to continue treatment. 

I have reported this case somewhat at length be- 
cause it was so misleading not only to me but to others, 
and also for the light that it throws on many ob 
scure cases of frontal headache, caused seemingly by 
muscular imbalance. I m.ike it an invariable rule to 
examine the nose in cases of muscular insufficiency 
and it has proved a very satisfactory practice to me, 
and I have the records of many cases in which the pa- 
tient has escaped the annoyance of wearing glasses 
by intranasal treatment. 

Case II. — A physician, aged thirty-three years. 
Family history good. He first came to me in 1895 
suffering from hay fever. He had enlarged lower 
turbinates which touched the septum. He had also 
chronic ethmoiditis on the left side of many years' 
standing. He told me that he had had frontal head- 
ache during some part of every day for ten years and 
that he had often been confined to his room for sev- 
eral days at a time with excruciating pain over the 
eyes. To use his own expression he had taken 
everything that had been prescribed for him, from 
aconitia to Rochelle salts, and knew of nothing that 



134 



THE INFRAPUBIC ROUTE IN SURGERY. 



[Medical News 



had relieved him. He further added that during all 
this time no one had ever examined his nose. 

His hay fever was easily controlled and later, 
during the fall, the lower turbinates were thoroughly 
cauterized. As soon as the burns were healed his 
headaches vanished and have not since returned. 
The ethmoiditis still continues but it is much better 
by reason of the better drainage. 

It may be claimed that the pain in this case was 
due to the ethmoiditis, but it should not be forgotten 
that the ethmoiditis was one-sided and that the pain 
was as often on one side as the other, and that the 
pain was quickly relieved by the cauterization, while 
the ethmoiditis still exists after four years of im- 
proved drainage. 

Another very common form of intranasal disease 
which causes headache is acute ethmoiditis. It is 
very often the case that an attack of acute rhinitis 
involves the anterior ethmoid cells and the inflam- 
mation remains in the cells for some time after the 
general attack has ceased. When these cells are in- 
volved the patient suffers from pain in and around 
the eye, which is often severe. The pain is so per- 
sistent and intense that the attending physician and 
the patient are fully persuaded that there is some 
serious disease of the eye. The following case is 
very characteristic of a large group: 

Case III. — Mr. P., aged forty-three years, suffered 
from an attack of grip with a good deal of inflamma- 
tion of the mucous membrane of the respiratory 
tract. During convalescence he complained of pain 
in the right frontal region, and around and in the 
right eye. I saw him in consultation and found the 
eye free from inflammation, pupil normal, and ten- 
sion not raised. On examination of the nose the 
left side was found free from disease. On the right 
side the anterior ethmoid cells were inflamed and 
the mucous membrane covering the middle turbinate 
was red, swollen, and covered with a thin watery 
discharge. A spray containing cocain relieved the 
pain and swelling, and under measures directed to 
the relief of the ethmoiditis he made a good re- 
covery. 

This case is reported simply as a type of a very 
common affection. Often the diagnosis is far from 
easy, but an inspection of the nasal cavities under 
good illumination cannot fail to be an aid in clearing 
up the nature of the case. 

Many patients have headache from a form of 
chronic rhinitis in which the discharge is not 
abundant, but rather viscid with a tendency to dry 
on tl*e^urface of the mucous membrane. The nasal 
breathing is not much obstructed except by the 
crusts, but the patients complain of a dull feeling of 
distress and discomfort across the bridge of ttie nose, 
extending upward across the brows, and at times giv- 
ing rise to decided pain in the eyes. This condition 



of the nasal mucous membrane is distinctly different 
from atrophic rhinitis, but it is rather closely asso- 
ciated with uricacidemia and is often made worse by 
high living. I have seen many cases in which over- 
indulgence in rich food made the nasal obstruction 
much worse in a few hours, and this result was so 
sure to follow any excess that the patients expected 
it. Measures directed to the systemic condition and 
regulation of the diet help these patients, but it is 
often necessary to treat the nasal disease by local 
applications. 

.\nother form of intranasal disease that causes al- 
most daily headache is hypertrophy of the posterior 
third of the middle turbinate. It is not at all a rare 
condition. The middle turbinate may touch the 
septum or approach it so closely that the narrow or- 
ifice is easily occluded by the congestion of the mu- 
cous membrane that follows any slight irritation. 
The headache from this condition is persistent and 
often severe and is only relieved by the removal of 
enough of the bony framework of the middle tur- 
binate to provide a good space between that body and 
the septum. This operation quickly, and I believe 
permanently, cures the pain. 

In this paper I have not attempted to discuss all 
the intranasal diseases which may cause headache, 
but have briefly alluded to some which seem to me 
to deserve more attention than they usually receive. I 
have no theory to offer to explain the production of 
headache by intranasal disease, but prefer to report 
the conditions as I have found them. At some 
future time we may be able to give a rational ex- 
planation of the connection between intranasal dis- 
ease and headache, but as yet our knowledge of the 
subject is too incomplete to justify us in the indul- 
gence of theories. 

In conclusion I wish to emphasize the following 
points: First, headache may be and often is caused 
by intranasal disease; second, other disease aside 
from atrophic rhinitis, nasopharyngitis, affections of 
the accessory sinuses or the obstructive intranasal 
conditions may be the cause of headache; third, an 
examination of a patient sutTering from headache is 
not complete unless the condition of the nasal cavi- 
ties has been investigated. 



THE INFRAPUBIC ROUTE IN SURGERY OF 
THE UTERUS AND ITS ADNEXA.' 

By\VlLLL\.\l H. WATHEN, M.D., 

OF LoniSVlLLE, KY. 

Four years ago when Drs. Jacobs, Henrotin, and 
I read papers before this society in Baltimore, upon 
surgery of the uterus and its adnexa per vaginam, 

' Read at the twenty-fourth annual meeting of the American 
Gynecological Society, held at Philadelphia, May 23, 24, and 25, 
i8qq. 



July 29, 1899] 



THE INFRAPUBIC ROUTE IN SURGERY. 



135 



the subject was so thoroughly discussed by the Fel- 
lows, and all questions in favor of the infra- and 
suprapubic methods of dealing with diseases of these 
structures were so carefully considered, that I then 
believed there would practically be unanimity of 
opinion as to what cases should be assigned to each 
of these methods. I find, however, that notwith- 
standing the fact that this question has since then 
engaged the attention of the best specialists in this 
country and abroad, we are but little nearer a con- 
sensus of opinion than we were before that meeting, 
and the arguments against the vaginal method pre- 
sented and answered upon that occasion are to-day 
urged with the same earnestness and honesty, al- 
though the experience of many men has demon- 
strated that facts do not justify such objections. 

It will not be claimed that there are no diseases 
of the uterus or the pelvic structures that cannot be 
successfully treated by either the supra- or the in- 
frapubic method, but nearly every objection to the 
latter is the result of a lack of observation or expe- 
rience. I have recently read with no little degree 
of surprise arguments against vaginal hysterectomy 
in the discussion of a paper before a medical society 
in Philadelphia. Were not these men representa- 
tive abdominal and pelvic surgeons I would not feel 
inclined to refer to their objections, for I would 
imagine that such opinions were unusual. This dis- 
cussion leaves the conviction that many surgeons 
have not carefully studied the technic of hysterec- 
tomy, etc. , per vaginam, but reproduce the theoret- 
ical arguments against such surgery that were 
advanced by the great surgeons of Paris in their 
opposition to the late Pean w^hen he first empha- 
sized his success in this kind of work. If we will 
read the arguments of the men at that time, and 
then the discussions against the vaginal method 
offered now, we will see the striking similarity and 
the same evidence of the theoretical character. But 
I dare say that had all our American surgeons prac- 
tically tested this method, as did Segond, Richelot, 
Pozzi, and others, they would have changed their 
opinions just as these men did, and would have 
learned that the objections they had supposed to ex- 
ist are not real. 

An experienced surgeon by the infrapubic route 
is surprised at surgeons who oppose this method be- 
cause of their repeated insistence that by the abdomi- 
nal route one can see the structures with which 
he deals, but cannot see the structures encountered 
by the vaginal route, for they have neither per- 
formed the operation correctly nor seen it cor- 
rectly performed. Any person who has often oper- 
ated by both methods will tell you that, with few 
exceptions, nearly every structure treated from below 



is brought in view before the knife or the si-issors 
is applied; and even in enucleation of pus tubes and 
ovaries, if we first bisect the uterus the eye can 
guide the finger as well as by any other method, 
and the finger can explore to the pelvic brim with 
its trained sense of touch. Nor will the statement 
that we must necessarily wound the intestines in in- 
frapubic operations more frequently than in supra- 
pubic operations bear the test of intelligent experi- 
ence. 

I have performed vaginal hysterectomy since 1888, 
and during the last few years have treated every dis- 
eased condition of the pelvis by this method, when 
indicated, if the consent of the patient could be 
obtained. During these eleven years I have never 
wounded the bowel or ureter; but I have wounded 
the bowel several times in performing abdominal 
section. I claim no special excellence of technic 
in avoiding injury to these structures, but contend 
that every well-trained surgeon can obtain the same 
degree of perfection in results if he will persist in 
his efforts. 

One thing that may have prevented the more 
general adoption of the vaginal method, and may 
have caused people to oppose it, is the belief that 
the technic is so complicated that it is difficult to 
do the work without committing the sins above men- 
tioned. I can understand why this belief exists to 
a greater extent than otherwise, in that too many 
surgeons use an unnecessary multiplicity of instru- 
ments, and especially of retractors, because these 
appliances, with few exceptions, are of no practical 
use and often complicate the operation. 

In my early hysterectomy operations I was prone 
to adopt the methods of my predecessors without 
considering whether there might probably be an 
improved technic in some details. In many cases 
in hysterectomy no retractor is needed, and seldom 
more than one, and by dispensing with them the 
operation may be performed more rapidly, more 
successfully, and with less danger of wounding ad- 
jacent organs, for the fingers are the best retractors 
that can be used. By this method, if we bisect the 
uterus there is usually no difficulty in seeing the 
tissues before the knife or the scissors is applied; 
but if we cannot the finger may be carried in advance 
of the cutting instruments, in contact with the uterus 
or diseased tissues, thereby preventing wounding 
the bladder, the intestines or the ureters. I have 
for several years observed this technic, and the more 
experience I have the more I feel justified in insist- 
ing upon its superiority. Every part of the vaginal 
wall and the cervix may often be exposed by the 
fingers and seen as plainly as tissues outside the 
body. 



136 



THE INFRAPUBtC ROUTE IN SURGERY. 



[Medical News 



I can readily see that there may be an objection 
to vaginal hysterectomy in some instances, and also 
to dispensing with retractors, if the uterus is not 
bisected; and just here is an excuse for the opposi- 
tion urged against vaginal hysterectomy by surgeons 
who tell us of the dangers of wounding vital structures. 
It is not possible to see all the tissues involved in 
removing pus-tubes and applying clamps if this is 
done before the uterus is bisected, because these 
structures are then high in the pelvis and mainly 
hidden from view. There is no danger, however, 
of wounding anything but the uterus during the 
process of bisection; and after the organ is divided 
each side may be separately pulled outside the vulva, 
adhesions treated as they present, and the broad 
ligament, including the ovaries and tubes, clamped 
externally from above, in full view. There is no 
danger of wounding the intestines in separating ad- 
hesions from the uterus, for it is exceptional that the 
bowel is firmly adherent to this organ, and if so, by 
hugging the uterus closely it is easily separated with- 
out danger of structural injury; and omental adhe- 
sions are of no consequence. 

While I do not believe the uterus is an important 
organ after the removal of the ovaries and tubes, 
still there are many cases in which it might be well 
to leave it, or in which the patient will not consent 
to its removal, and her convalescence may not, be- 
cause of this fact, be interfered with, and she may 
remain well. In these cases I have had but little 
difficulty in removing the ovaries and tubes through 
a vaginal incision into Douglas' pouch, going be- 
hind the ureters and the uterine arteries. If the in- 
cision is made close to the uterus no vaginal arterial 
branches will be wounded and hemorrhage will be 
of no consequence, nor will there usually be much 
trouble in separating adhesions and bringing the 
ovaries and tubes into the vagina. They can then be 
removed with almost as much perfection as they can 
through the abdominal wound. 

In this operation retractors are absolutely in the 
way, and no one can do perfect work of this kind 
who continues their use. And in this connection 
we may show the fallacy in the arguments against 
the infrapubic method offered by persons who claim 
it is not conservative, for it is impossible to perform 
more conservative surgery upon any part of the body, 
or by any known method, where the operation could 
in any sense be considered a capital operation. 

There is no danger in opening Douglas' pouch 
after the vagina has been made aseptic, and the 
uterus likewise, by thorough curettage, etc. ; and 
when the ovaries and tubes are brought into the 
vagina, if not diseased, they may be returned with- 
out injury, but if diseased not enough to justify re- 



moval they may be treated by any approved method, 
returned to their place, and the vaginal incision 
immediately closed. The operation performed after 
this fashion is of so little significance that it is not 
more dangerous than the operation for curetting and 
for lacerated cervix, and the patient, having no 
elevation of temperature or rapidity of pulse, is able 
to leave her bed at any time the surgeon will permit 
her to do so. 

If there is doubt as to whether the ovaries and 
tubes are diseased sufficiently to justify the removal 
of one or both adnexa we should first carefully ex- 
amine these organs through an opening into Douglas' 
pouch, and if neither should be removed, or if one 
should be removed only, be governed by the indi- 
cations. 

Nothing more could be accomplished by the su- 
prapubic method, and by that method the abdominal 
wound in itself should confine the patient to bed for 
not less than two weeks, and require an abdominal 
support for one year; and in the vaginal method of 
exploration there is no danger of hernia or post- 
operative intestinal adhesions, while there is danger 
in the abdominal method, whether any organs are 
removed or adhesions separated. This is proven by 
observation in operations for ventral hernia follow- 
ing celiotomy, and we are always watchful in our 
incision to prevent wounding an intestine adherent 
to the abdominal wound. 

When but one ovary and tube should be removed, 
let it be as a result of any kind of injury — pyosal- 
pinx, ovarian abscess, tuberculosis, extra-uterine 
pregnancy, etc. — the other side may serve just as 
useful purpose as before the operation, and many of 
these women have afterward borne children without 
trouble. While there may be a few cases where the 
operation could not be completed without hysterec- 
tomy or abdominal section, I have not met with 
such a case, and I have not performed the suprapubic 
operation for extra-uterine pregnancy for nearly 
four years, but have performed about thirty through 
the vagina, each patient making an uninterrupted 
recovery. When one or both of the adnexa are 
removed per vaginam the convalescence is so univer- 
sally uninterrupted that we learn to believe that 
every patient will make a prompt recovery. Of 
course it would not be the correct thing to attempt 
to complete an operation for extra-uterine pregnancy 
in intraperitoneal rupture with a large accumulation 
of blood in the abdominal cavity that could not be 
drained away; but in this condition there are times 
when vaginal incision into Douglas' pouch, and 
clamping the tube at the point of rupture, may save 
the life of the woman by promptly controlling hem- 
orrhage until she can be resuscitated sufficiently to 



JfLV 29, .899J 



THE SERUM-TREATMENT AND ITS RESULTS. 



•37 



resist the dangers of a celiotomy. In some of these 
cases the shock is so great that an abdominal section 
cannot be performed until the patient rallies, and 
often just as the pulse begins to become well per- 
ceptible secondary bleeding may cause death. A 
clamp may be applied through the vaginal incision 
without the administration of chloroform if the pa- 
tient is not able to take an anesthetic, and removed 
at the time of the celiotomy. 

Having first insisted at the meeting in Baltimore 
that in operations per vaginam, when septic matter 
in the pelvis is held there by an over layer of intes- 
tines agglutinated by inflammatory exudations, that 
these adhesions should never be disturbed if it can 
be avoided, and that e.xperience has taught that they 
usually cause no trouble, I will not dwell specially 
on that point to-dar. Nature is always conserva- 
tive, and in protecting the abdominal cavity from 
the poisons in the pelvis she usually does so after a 
systematic fashion that may cause no trouble if the 
adherent intestines are not separated, and this pro- 
tecting roof should not be disturbed, either in vagi- 
nal incision or in vaginal hysterectomy. No expe- 
rienced celiotomist will contend that it is not 
dangerous to remove a large accumulation of pus, 
hemmed in after this fashion, through the abdominal 
incision, for while it may be sterile in one instance 
it may be virulent in another, and we never know 
that we can positively prevent soiling the healthy 
peritoneum; but if we succeed in separating the ad- 
hesions without wounding an intestine or causing 
local or general sepsis, it is impossible to prevent 
post-operative irregular adhesions more dangerous 
to health and life than would have been the aggluti- 
nated intestines left undisturbed in an operation per 
vaginam. Patients in whom there is an exten- 
sive accumulation of pus, with tissues thoroughly 
septic and softened, may symptomatically re- 
cover by incision and drainage without the removal 
of any organs, and I have seen many of these who 
afterward did not complain of pelvic trouble. This 
is applicable in accumulations of pus following abor- 
tion or labor; but in cases of local sepsis at 
such times the formation of pus may be prevented 
by prompt vaginal incision, opening the folds of the 
broad ligament, or separating pelvic adhesions, and 
lightly packing with iodoform gauze, so as to sepa- 
rate and keep apart the infected surfaces. If these 
cases could be seen at the beginning of sepsis the 
results would be good, but unfortunately we are not 
often called until the disease has made too much 
headway and pus has accumulated. 

In both vaginal hysterectomy and vaginal incision 
for removal of tubes and ovaries, or for other pur- 
poses, we should apply just as little gauze as will 



meet the demands, being careful to cover the ends 
of the clamps to protect the intestines against sub- 
sequent injury. Too much gauze packing is pain- 
ful, keeps the vaginoperitoneal opening too widely 
distended, and does not drain well. But little iodo- 
form gauze should be used, for it has often caused 
intoxication, and has occasionally caused death. 

To insure perfect drainage it is best to place a 
gum tube in the vagina with the end in the lower 
part of the vaginal incision and against the gauze 
packing. The tube should be used until after the 
gauze has been removed, and until the opening be- 
tween the vagina and peritoneum has closed so as to 
positifdy resist the passage of water in vaginal irriga- 
tion. I do not believe it is best to leave the gauze 
packing for a week or ten days, as has been done, 
but I remove it gradually, beginning on the third 
day and taking out the last piece on the fifth or 
sixth day. 

I have never observed that the length of the 
vagina has been materially altered, or that the se- 
cretion has been especially interfered with. If an 
appendix is sufficiently diseased to justify its re- 
moval, then the direct symptoms will enable us to 
make a diagnosis and guide us in the selection of 
the best method in operating. The relatively de- 
layed convalescence, the abdominal incision, and 
the danger of hernia must be accepted in a minor 
degree as objections to the suprapubic route in 
selecting that method instead of the infrapubic route. 



THE SER U M - TR E ATMENT AND ITS RE- 

SUL TS. 

By HERVI.\NN M. BIGGS, .M.D., 

OF NEW YORK. 

(Concluded from page 105.) 

Pneumonia. — There is no disejise, excepting pos- 
sibly tuberculosis, which is more fatal and in which 
a specific preventative and curative method of treat- 
ment is more to be desired than in pneumonia. The 
records of the New York City Health Department 
show that the deaths ascribed to pneumonia of dif- 
ferent varieties number on the average about 5000 a 
year and are only exceeded by those due to the 
tubercular diseases. 

Since 18S4, when A. Friinkel first separated the 
pneumococcus in fresh culture, numerous bacteriolo- 
gists have endeavored to produce immunity against 
the processes caused by this organism. In animals 
many methods have been employed to obtain this 
result with varying success. 

The technic of experimentation with the pneu- 
mococcus has always offered unusual bacteriological 
difficulties and these have deterred many experi- 
menters and have no doubt delayed the accomplish- 



THE SERUM-TREATMENT AND ITS RESULTS. 



[Medical News 



ment of the desired result, but the stimulus given by 
the success in obtaining antitoxic serums for tetanus 
and diphtheria has induced in recent years renewed 
efforts to obtain a curative serum for pneumonia in 
man. 

The Klemperer brothers in 1891 reported some- 
what favorable results from the treatment of six cases 
of pneumonia by an antipneumotoxin precipitated 
from the blood of immune rabbits; Jansen later re- 
ported apparently favorable results in ten cases of 
pneumonia treated by the injection of the serum of 
immune rabbits, and in 1S93 Lara and Botzolo re- 
corded what they regarded as encouraging results. 
In 1896 DeRenzi recorded the results obtained 
from the treatment often cases of pneumonia with 
antitoxic serum, and while all recovered the author 
felt unwilling to say they might not have recovered 
without the use of the serura. In 1897 Weisbacker re- 
ported five cases treated by injections of serum ob- 
tained from patients convalescent from this disease, 
and while the objective symptoms do not seem to have 
been much affected by the treatment the subjective feel- 
ing of relief is said to have been marked in all and re- 
covery in all occurred. Washburn immunized a 
pony and with the serum thus obtained treated two 
cases successfully. He describes a method for de- 
termining the antitoxic power of the serum em- 
ployed. Parre reports the results of experiments 
made with serum obtained from an ass, a cow, and 
rabbits thus immunized, in which he found the 
serum of the ass most efficacious. He reported 
twenty-two cases of pneumonia treated with this 
serum, with two deaths, these two patients being 
practically moribund when the serum was ad- 
ministered. In a later article he states that he is 
using the serum systematically, and that when given 
in 50 c. c. doses early in the disease, crisis and re- 
covery invariably followed. 

Ughetti of the University of Cantania and Can- 
tieri. Director of the Medical Clinic at Sienna, ex- 
press favorable opinions as to the efficacy of the 
serum prepared by Parre, while Massolongo of 
Verona concludes a careful and minutely detailed re- 
port as follows: "My impression as to the value of 
the antipneumococcus serum is that it is more effica- 
cious in the treatment of pneumonia than any other 
agent we possess. These first lexperiments of mine 
convince me that from the DeRenzi and Parre 
serum we can obtain a clearly defined action on the 
pneumonic process, which it influences directly." 
Nine other clinicians have recorded similar experi- 
ences during the last year and have communicated 
the results to the Sero-Therapeutic Institute at 
Naples, where the serum is prepared. 

Some experiments instituted along this line in the 



laboratories of the Department of Health, while still 
incomplete, give encouragement to hope for ulti- 
mately successful results. It is undoubtedly possible 
to confer upon animals (horses being employed in 
these experiments) a high degree of immunity to vir- 
ulent cultures of the pneumococcus and the serum de- 
rived from these animals in very small amounts will 
protect rabbits from many times a fatal dose, when 
administered before the inoculation of virulent cul- 
tures of pneumococcus. The controls invariably die 
from the injection of -j-jVo P^''* "^ ^^^ ^^^^ adminis- 
tered to the protected rabbits. A larger quantity of 
the serum is required to protect animals when the 
culture is administered at the same time or previous 
to the administration of the serum, but even then, if 
the administration of the serum is not delayed for 
too long a period, the rabbits still live. 

The conditions obtaining in such experiments are 
quite unlike those ordinarily existing in pneumonia 
in the human being, as pneumococcus septicemia is 
ultimately produced by the inoculations and this 
does not occur, as a rule, in lobar pneumonia in 
human beings except in severe cases and late in the 
disease. The animals, in these experiments, which 
showed a general septicemia at the time of the ad- 
ministration of the serum invariably died, but lived 
longer than the controls. Those animals which 
did not show a general septicemia at the time of the 
serum injection have in part lived and in part died. 
Successive doses also seem sometimes to save animals 
which would otherwise have perished. 

The practical results obtained in the treatment of 
pneumonia in the human being with this serum are 
indecisive. The experimental results, however, are 
striking and justify a hope that better results may be 
later obtained with improved methods, and a serum 
of higher grade. 

It is undoubtedly important in this disease as in 
the other infectious diseases in which the serum 
treatment has been successfully employed, that the 
remedy should be administered at an early stage of 
the disease. 

It seems quite within the range of possibility that 
the next great achievement of serum therapeutics 
will be in the production of an efficient antipneumo- 
coccus serum, and if this should be obtained all of 
the previous successes in this department of medi- 
cine would in practical importance be far surpassed. 

Epidemic Cholera. — Encouraging results have been 
obtained in both the preventative and curative treat- 
ment of epidemic cholera. Extensive investiga- 
tions were carried on by Haffkine under the super- 
vision of the English Government in India, in 
regard to the use of preventive inoculations for chol- 
era. More than 100,000 persons are reported to 



July 29, 1899] 



THE SERUM-TREATMENT AND ITS RESULTS. 



139 



have been subjected to these inoculations, the mate- 
rial used in them being the dead cultures of the 
cholera bacillus. The inoculations in themselves 
are harmless although they are followed by some 
local and general reaction, which is, however, of 
short duration. To confer complete immunity Haff- 
kine's method requires two inoculations with an in- 
terval of about eight days between them. 

The following may be considered as indicating 
fairly the general results obtained from these inocu- 
lations: 

The managers of certain tea estates, among the 
coolies of which the inoculations were carried on, 
reported that out of 29,000 employed on the estates, 
7507 had been subjected to the inoculations; among 
these 63 cases of cholera afterward occurred, with 
28 deaths — the admissions thus being 8.39, and the 
death-iate 3. 73 per 1000. Among 21,443 coolies 
not inoculated, in the same gardens, there were 260 
admissions, with 150 deaths from cholera, showing an 
admission-rate of 12.13, and a death-rate of 7 per 
1000, or about twice the rate among the inoculated. 
The majority of those inoculated were only sub 
jected to one inoculation with the weaker virus, 
which according to Haffkine, gives only partial re- 
sults. In a small set of experiments carried on by 
Surgeon Hare after Haffkine' s departure, 196 out of 
355 coolies on one estate were inoculated; 4 of the 
inoculated coolies were seized with cholera and died 
Among those not inoculated there were 34 cases and 
30 deaths during the same period. These figures 
give admission- and death-rate among the inoculated 
coolies as 20.4 per 1000, while among the non-ino- 
culated coolies the admission-rate was 213.8, and 
the death-rate 188.7 pcr 1000. It is also reported 
that in a later series even better results were obtained. 

As to the curative value of the anticholera serum 
we may refer to the experiments of Kitisato, which 
show that in the Hirdo Cholera Hospital the mortal- 
ity fiom cholera was apparently reduced by 20 per 
cent, by the use of the serum, and that in early 
cases — that is, those treated within the first twelve 
hours of the disease, the mortality was reduced to 
about 14 per cent, instead of the average 70 per 
cent, among those treated in some other manner. 
Experimentally it has been shown that the serum 
protects guinea-pigs from the results of the inocula- 
tion of many times the fatal dose of a cholera cul- 
ture, when injected simultaneously into the perito- 
neal cavity. When injected subcutaneously, 
somewhat larger quantities of serum were required 
to confer protection; but this was still obtained if 
the curative injection was not made too long after 
the infection. 

Koch said to the writer two years ago, with rela- 



tion to the protective inoculations against cholera, 
that he had no doubt that in any future outbreaks 
of cholera in Europe or in America the disease 
would be promptly controlled through the use of 
immunizing injections, and that a maritime 
quarantine against this disease would be no longer 
required, as persons exposed on shipboard would be 
immunized and thus protected. 

Bubonic Plague. — Still more encouraging results 
have been obtained in the preventative and curative 
treatment of the bubonic plague. The method 
adopted in testing the treatment consisted in the se- 
lection of a group of persons living under similar 
conditions, inoculating a portion of this group and 
leaving the remainder uninoculated, and then noting 
the incidence of the disease in the two groups. 

At Kirkee, where plague broke out among the ar- 
tillery, an excellent opportunity with these condi- 
tions presented itself, and the results were as fol- 
lows: Among 875 non-inoculated men there were 
133 cases of plague with 102 deaths, while among 
667 inoculated, there were 32 cases with 18 deaths. 
The figures are strikingly in favor of the inoculated, 
for if the inoculated had had projiortionately the 
same number of deaths as the non inoculated, they 
would have had 89 deaths instead of 18, a difference 
of 71 deaths, a reduction of nearly 80 per cent. In 
Damann the results were equally good. In this 
small town Haffkine inoculated altogether 2297 per- 
sons. Of 6933 persons in the town who were not 
inoculated 1482 died, z'/s. , 24.6 per cent., while of 
the 2297 inoculated, only 36 died, or 1.6 per cent., 
instead of 332, which would have been the number 
had the deaths been in the same proportion as among 
the non-inoculated. In this series there was a re- 
duction of 89.2 per cent. To meet objectors Haff- 
kine and Lyons point out that with such results and 
so high a proportion of the inoculated to the rest of 
the inhabitants (2297 to 6933) it is impossible that 
the inoculated represented the upper or any particu- 
lar class of the population to which their reduced 
death-rate could be ascribed. A notable example is 
given in theParsee Community which consisted of 306 
persons, of whom 277 were inoculated, leaving only 
29 uninoculated. In the 29 uninoculated there were 
4 deaths from plague, or a mortality of 13.8 per 
cent., while among the 277 inoculated there were 8 
attacks with only i death, which occurred in a 
woman ill of plague before the inoculation. Count- 
ing this death the mortality in the inoculated was 
0.36 percent, or 38. 3 times lower than in the uninoc- 
ulated. Again, in Lanowli, where inoculations were 
carried out in two infected and isolated centers, 422 
non- inoculated had 68 cases and 48 deaths, and 293 
inoculated had 5 deaths. If the deaths among the 



I40 



THE SERUM-TREATMENT AND ITS RESULTS. 



[Medical News 



inoculated had been proportionately as high as among 
the non-inoculated there would have been ^;^ deaths 
instead of 5, a difference of 2S deaths, or 84 per 
cent. 

The observations in Bombay and Mora are less in- 
structive, because they are not comparative; still they 
are interesting, and confirmatory of the favorable 
influence of the inoculations. In Bombay 8142 per- 
sons were inoculated, and among this number 18 
were attacked with plague, 1 6 of whom recovered 
and 2 died. The 2 fatal cases were ill with plague 
at the time of inoculation. In Mora Kolaba,a small 
place in which plague appeared, 419 of the inhabi- 
tants were inoculated; 4 of these were attacked, but 
all recovered. .\ careful analysis of the results of 
the inoculation seems to show that the efficacy of the 
prophylactic depends on the virulence of the bacil- 
lus from which the lymph is prepared, and on the 
dose and its power of producing a well-marked 
febrile reaction, and that it is more effective in pre- 
venting deaths than attacks. 

Typhoid Fever. — Wright and Sample have em- 
plo^'ed Haffkine's method of vaccination' against 
cholera in the prophylaxis of typhoid fever. The 
vaccines are made from agar cultures of typhoid ba- 
cilli which have been grown for twenty- four hours 
in the incubator. Cultures thus obtained are emul- 
sified by the addition of measured quantities of 
sterile broth. The resulting emulsion is then drawn 
up into a series of sterile and calibrated glass pi- 
pettes, the capillary ends of which are sealed in the 
flame so as to form vaccine capsules. The capsules 
are then placed in a beaker of cold water which is 
brought to a temperature of 60'' C. and kept at that 
temperature for five minutes. The vaccines are in- 
oculated into the flank. The strength of a typhoid 
vaccine will obviously be determined (i) by the 
number of bacilli which it contains, (2) by the vir- 
ulence of these bacilli. In their later experiments 
they emplo)ed a typhoid culture of such strength 
that one fourth tube of twenty- four hour culture 
constituted a lethal dose for a guinea-pig of 350 to 
400 grams when hypodermically injected. The 
quantities of this culture used for antityphoid vac- 
cinations varied from one twenty-fifth to one-fourth 
of a tube. The latter quantity (i.e., the (quantity 
which, if injected alive, would have proved fatal to 
a 350 gram guinea-pig) constitutes a somewhat 
severe dose for a man. 

Clinical Symptoms. — When the smaller doses (one- 
twenty- fifth to one-sixth of a tube) are used the 
symptoms are comparatively slight. The local 
symptoms consist in a little tenderness; the con- 
stitutional symptoms in a subjective feeling of 
chilliness, which comes on about two or three hours 



after the inoculation of the vaccine; further, in a 
very slight rise of temperature and a little restless- 
ness at night. The symptoms have quite passed off 
in twenty-four hours. With larger doses the symp- 
toms are all more severe. There is considemble 
local tenderness and inflammation, which disappear 
after forty- eight hours. The constitutional symp- 
toms, consisting in some degree of faintness and 
collapse, begin to manifest themselves generally 
in two to three hours. In 4 out of 1 1 cases 
inoculated with the larger doses faintness and 
nausea (resulting in i case in vomiting) were al- 
ready well marked after three hours. In the other 
7 cases these symptoms supervened later. Only 3 
out of the II cases were able to put in an appear- 
ance at dinner. A good deal of fever was devel- 
oped in all cases, and sleep was disturbed. By the 
next day S out of the 11 persons treated returned to 
their normal condition of health; 3 of the 11 looked 
somewhat shaken in health for sonie weeks after. 
Calcium chlorid (45 to 60 grains) was administered 
with a view to prevent a decrease of blood coagula- 
bility. Examined by the Widal-test the results 
showed in the most evident manner that the blood 
of patients who have submitted themselves to an an- 
tityphoid inoculation becomes in some measure 
poisonous to the typhoid bacillus by giving the re- 
action of immobilization and agglutinization, and it 
may be inferred that these persons are immunized 
against typhoid fever. This conclusion, however, 
cannot be regarded as assured until we are in a po- 
sition satisfactorily to account for the fact that ty- 
phoid-fever patients and Malta- fever monkeys who 
succumb to these diseases show the specific sedimen- 
tation reaction in exactly the same way as the ty- 
phoid-fever patients and Malta- fever monkeys who 
recover from these diseases. (Wright andSemple.) 

With regard to the danger associated with anti- 
typhoid vaccinations, Wright and Semple say: 
"When we appreciate that the bacteria which are 
employed in these vaccinations are dead bacteria, 
and that they are incapable of generating new 
poison in the system, it will be obvious that the in- 
jection of small and measured quantities of these 
dead bacterial cultivations involves no more risk to 
life or health than the injection of a medicinal one 
of morphin. That there is no unknown factor of 
risk in the case of the injection of bacterial toxins 
will be evident when we consider that Haffkine has 
performed nearly 100,000 anticholera inoculations 
without a death, and as far as we can learn without 
the supervention of a single serious symptom. 

"Although there are no facts as yet upon which 
to base definite conclusions, it is legitimate to judge, 
from the extremely slow disappearance of the per- 



July 29, 1899] 



THE SERUM-TREATMENT AND ITS RESULTS. 



Ui 



fectly comparable 'sedimentation' power, which is 
acquired by undergoing an attack of typhoid, there 
is every reason to hope that the immunity which is 
conferred by these vaccines may persist for a consid- 
erable number of years. If it does so it will obvi- 
ously suffice to carry a young adult over the period 
of his extreme susceptibility. ' ' 

As to the sphere of application of the prepared 
antityphoid vaccinations, they suggest, since these 
vaccinations are unattended with risk, that it would 
be expedient for every one who is likely to be fre- 
quently exposed to the risk of typhoid infection to 
undergo ti:e vaccination. In particular this would 
appear to be expedient in the case of young soldiers 
going to typhoid-infected districts, to nurses in at- 
tendance upon typhoid patients, and to persons who 
are living in any district which is being visited by 
an epidemic of typhoid. 

Semple later reports as regards the value of these 
prophylactic inoculations, that out of 84 persons vac- 
cinated against typhoid during an epidemic, not one 
contracted the disease, while of 120 not vaccinated, 
under the same conditions 16 were attacked by it. 

Sanarelli' s Anti-a7iiarylic Serum for the Treatment 
of Yelloiv Fever. — It is claimed that this serum is 
germicidal to the microbe causing yellow fever, while 
it is impotent against the poisoning produced 
by this organism. Successful results, it is said, can 
only be obtained by the injection of the anti am- 
arylic serum very early in the course of the disease 
(before the microbe has become firmly lodged and 
has produced diffuse poisoning), then the yellow- 
fever bacillus is destroyed, and the disease is cut 
short. 

Sanarelli says that good results are difficult to ob- 
tain if the treatment be applied when the disease is 
already advanced after the amarylic poison has largely 
accumulated in the organism and has already in- 
duced grave anatomical and functional changes 
which the serum is powerless to counteract, and 
which of themselves suffice to cause death. The ap- 
plication of the serum, therefore, must be confined 
to the first period of the malady. 

"The serum, itself, is in no respect harmful and 
can be administered in the desired quantity up to 
the moment when all hope of success is not yet def- 
initely abandoned. The beginning dose is 20 c.c, 
and if this is followed by no appreciable improve- 
ment, a second, third, or further doses may be ad- 
ministered according to.the patient's general condi- 
tion. Injections may be made subcutaneously in the 
thigh or nates, but in urgent cases it is preferable to 
introduce the serum directly into a vein of the fore- 
arm." 

Wasdin, who employed it in several cases in Louisi- 



ana says that in one case there was a very prompt 
reaction, evidenced by the rise of temperature and 
pulse, and the great redness of the face and skin of 
the body. This was followed by a cessation of all 
pain in a few hours and a fall of temperature and 
pulse to a point lower than before administration. 
The second and third injection showed less marked 
reaction. The exhibition of the serum produced 
free secretion of a non-albuminous urine, some ptyal- 
ism, and free perspiration, but Wasdin thinks the 
patient would have done equally well with other 
medication. The second case he thinks would have 
undoubtedly done as well without any medication. 

"The influence of the serum upon the vasocon- 
strictors was very pronounced, causing mental and 
physical suffering. At first the urine was free and 
always non-albuminous, but on the second day be- 
came diminished although the skin acted freely. A 
rash was produced, partly urticarial and partly ery- 
thematous. The reaction in this second case was 
excessive, the temperature rising to 104*^. The doses 
administered were 10 c. c. each; the full dose advised 
was 20 c. c." Wasdin felt satisfied that the larger 
dose would have caused much alarm and probably 
harm. 

Cases seen in this epidemic were so mild that he 
did not feel justified in injecting a greater number 
of persons and subjecting them to the risks attendant 
upon the use of a remedy with the results of which 
he was unacquainted. 

Streptococcus Infections. — Infections due to the 
streptococcus have long been the subject of experi- 
mental investigations and many bacteriologists have 
endeavored to produce a curative serum for their 
treatment. The difficulties in the way of success are 
numerous and have thus far been only to a limited 
extent overcome. 

It has been shown by many experi mentors that it 
is possible to immunize animals by the inoculation 
of rapidly increasing doses of living and virulent 
streptococcus cultures, so that their serum finally 
possesses the power to protect rabbits under special 
conditions against infection from many times the 
fatal dose of the special streptococcus used for the 
inoculations. The protective power of this serum is 
specific. It does not exist in normal serum or in 
the serum of animals immunized against any other 
organism. Unfortunately, however, this serum more 
rapidly loses this characteristic power than tetanus 
or diphtheria antitoxic serum, and often is practically 
inoperative six weeks after its withdrawal. It has 
been further shown that this serum does not neces- 
sarily confer immunity to any other streptococcus 
than the special one which has been employed in the 
original inoculations. It may be almost powerless 



142^ 



THE SERUM-TREATMENT AND ITS RESULTS. 



[Medical News 



against some pathogenic streptococci, while it is 
strongly protective against others. Like other anti- 
toxic serums it produces its most marked effects 
when introduced before the inoculation of the strep- 
tococcus cultures. If introduced at the same time 
as the culture it is more active when injected in the 
same area with the cultures than when introduced on 
the opposite side of the body of the animal. A 
series of experimental investigations on the produc- 
tion of this serum has been carried on in the labora- 
tories of the Department of Health for more than 
three years, and the conclusions which have been 
reached by other experimentors have been fully 
verified. 

The results obtained from the practical use of an- 
tistreptococcus serum in septic infections in the 
human being have been of the most conflicting na- 
ture. Some observers have reported excellent re- 
sults in a number of cases, while many others have 
found the serum almost valueless. The practical re- 
sults are fully in accord with the conclusions deduced 
from the experimental investigations. Undoubt- 
edly in some instances the serum has proved of value 
when used in the human being. These were cases 
in which the serum employed did exercise a protec- 
tive influence against the special organism producing 
the infection, and in which the infection was proba- 
bly not of a very intense nature and a general strep- 
tococcus septicemia did not exist. 

In the majority of instances in which it has been 
used clinically it probably has not been of any value. 
This result should be expected for a number of 
reasons. In the first place many of the preparations 
of serum had undoubtedly lost such power as they 
may have originally possessed before they were used 
for the treatment of human beings; second, the pro- 
tective power originally was not sufficient in the 
doses in which it was employed to have been of 
much value even if introduced when fresh; third, 
there is little evidence to show that this serum is of 
much value when a severe general septicemic condi- 
tion exists; fourth, in many instances the infection 
has been due to some pathogenic streptococcus dif- 
ferent from that employed in the inoculation of an- 
imals from which the serum was obtained and 
against which the serum would have no power; fifth, 
many of the cases in which it has been employed 
were not cases of streptococcus infection at all, but 
were infections due to entirely different organisms, 
as the staphylococcus, colon bacillus, pneumococ- 
cus, etc. 

It may, therefore, be assumed, from what has 
been said, that at present the practical value of this 
serum is limited. This feeling has been so strong 
in the Department of Health that it has never been 



considered wise to issue it for general use, and while 
it can be obtained by public institutions or private 
physicians in this city on application for the treat- 
ment of cases of septic infection on condition that 
the results obtained are reported to the Department 
of Health, yet its use has never been recommended 
or encouraged because it was felt that the experi- 
mental results did not justify such action. It should 
be added, further, that these conclusions do not ap- 
ply solely to the preparation produced in the labora- 
tories of the Department of Health, but to all prepara- 
tions which have thus far been tried experimentally. 
The experience of the writer in the useof this serum, 
and the reports which have been received from those 
who have employed the serum entirely confirm 
these conclusions. It does not follow, however, 
that we may not ultimately obtain a preparation 
which will have definite practical value. 

It should be said in passing that a large propor- 
tion of the cases of infection supposed to be due to 
the streptococcus are on bacteriological examina- 
tion shown to be due to other organisms. In five 
of the last six cases treated with the serum produced 
in the laboratories of the Department of Health 
bacteriological examinations were made, and in 
three the infection was found to be due to other 
germs. 

I have not taken up the consideration of several 
diseases of animals in which remarkable results have 
been obtained, especially in the preventive treat- 
ment, i.e., rabies, tetanus, anthrax, and rinderpest, 
because of the lack of time, and nothing of special 
importance has been recently added to our knowl- 
edge of the three first, while the work on rinder- 
pest, although apparently successful, is still in the 
experimental stage. 

It may be useful to consider just for a moment, 
finally, what has been thus far accomplished in the 
preventive and curative treatment of various infec- 
tious diseases by the use of substances of bacterial 
origin. 

Leprosy and tuberculosis may be, in my opinion, 
entirely thrown out of consideration. There is no 
satisfactory evidence as yet adduced to show that in 
either of these diseases anything has been accom- 
plished either in the prevention or cure. In three dis- 
eases in the human being, rabies, tetanus, and diphthe- 
ria, and anthrax and probably rinderpest in animals, 
we have perfectly efficient means for conferring im- 
munity which are practically, available. It further 
seems probable that immunity may be also conferred 
to snake venom. There is also very strong evi- 
dence of the practical value of the protective inocu- 
lations against cholera and plague. All the work 
with reference to typhoid fever, streptococcus infec- 



July 29, 1899J 



THERAPEUTIC NOTES. 



143 



tions, and pneumonia must be considered as only in 
the experimental stage. 

When the curative treatment is considered, in 
only one disease can it be said that serum-therapy 
has afforded us a perfectly satisfactory method of 
treatment, that is in diphtheria. In all of the others 
all of the practical problems remain as yet unsolved, 
but in some there is a reasonable prospect of an early 
solution. 

MEDICAL PROGRESS. 



Subcutaneous Rupture of a Hydrocele. — Mackenzie 
(Briy. Med. Jour., May 27, 1899) reports an instance of 
a rather rare accident, the rupture subcutaneously of a 
recurrent hydrocele. It was associated with a scrotal 
hernia, for which a truss was worn. The patient, a 
plasterer, aged 48 years, was reaching below his scaffold, 
and as the truss pressed upon the top of the hydrocele, he 
felt something burst. There was no great pain. There 
was swelling of the penis, but this disappeared the follow- 
mg day under a cold application and rest in bed. The 
fluid reaccumulated, but not so rapidly as it did after 
tapping. 

"rotrusion of the Intestines in a New-born Babe. — BELL 
{^Lajicet. June 3, 1899) was called upon to treat a 
Chinese baby in whom two feet of the intestines protruded 
from a rent in the much dilated and thinned base of the 
umbilical cord. The intestine was washed and returned 
to the abdominal cavity, and the cord was ligated, and 
cut off. This ligature slipped in a few hours, and the 
intestines again escaped. They were returned a second 
time and the rent was sutured. There was no peritonitis, 
and the wound healed firmly, although cicatrization was 
not complete until the twenty-first day. 

Dilatation of the Anus for Vesical Pain. — Guepin {Rev. 
de Tlierap. Medico-Chirurg., June 1, 1899) states that 
anal dilatation is a palliative measure which ought not to 
be omitted from the treatment of incurable, painful, and 
spasmodic affections of the ureters and bladder. It is 
also a proper preliminary measure in certain major opera- 
tions on the urinary tract. 



THERAPEUTIC NOTES. 



Muscular Development as a Radical Cure of Hernia. — 
Warden {Lancet, June 10. 1899) says thai many 
cases of hernia can be permanently cured by the system- 
atic development of the abdominal muscles. An exam- 
ination of the external rings of an athlete will show one 
how firm and small they are, and how much less is the 
cough impulse, than that felt in an ordinarily muscular 
person. The advice that is often given to a patient 
whose hernia is treated by a truss, is to avoid muscular 
exertion. Following these directions his abdominal walls 
become flabby, whereas if he takes more exercise than be- 
fore they will be growing stronger. Warden has seen a 
great change in the ring, after three- or six-months' regu- 



lar exercise. He proposes three forms of exercise as espe- 
cially adopted to such cases: (i) In dorsal decubitus, 
with the hands at the sides, the patient is to raise his 
body from a lying to a sitting posture. (2) In dorsal 
decubitus, let him raise both legs from a horizontal to a 
vertical position. (3) Let exercise No. i be performed 
in such a manner that the body sweeps toward one side 
before coming to an upright position, describing a curve 
and bringing into play the obliques. Each of these 
movements should be performed twenty or thirty times, 
or until a distinct sense of weariness is produced. 

Clinical Report on Heroin. — BekettOV ( f(-Va/ir/:,No. 19, 
1899) has given to twenty-five patients the product of mor- 
phin and acetic acid, called heroin. The dose used was 
^V-7-grain, in the form of a powder. He found that it less- 
ened cough, so that patients were able to sleep, who be- 
fore had been kept awake by constant coughing. If there 
was an increased respiration from cough or painful 
pleurisy, under the influence of heroin the respirations be- 
came slower and deeper. If, however, dyspnea was due 
to some cardiac condition, or to diminished pulmonary 
surface, as when cavities were present, it was not af- 
fected by the heroin. The drug had no effect on the cir- 
culatory or digestive systems. It produced sleep if the 
cause of insomnia was pulmonary. In wakefulness due 
to nervous conditions it was not so satisfactory. In 
hemoptysis it seemed the ideal remedy, preventing cough 
which is so disastrous under such circumstances. Some 
patients became accustomed to the drug, so that the dose 
had to be increased slightly; in others the same dose pro- 
duced the same therapeutic effect although the adminis- 
tration was continued for weeks. In no instance was 
more than >^-grain given during the twenty-four hours, 
nor a larger single dose than .^J- -grain. 

Chloral in Typhoid Fever — Du.MONT {Rev. de Tkerap. 
Medico-Chir., May 15, 1899) describes the effect of the 
administration of chloral, sometimes associated with mor- 
phin for persistent insomnia occurring in typhoid fever. 
This method of treatment has been carried out in Lan- 
cereaux' wards with good results. Not only did sleep 
follow, but restlessness, delirium, and nervous exhaus- 
tion were thereby prevented. As a natural consequence, 
the general condition of the patient was improved, and 
the duration of the fever, as well as that of convalescence 
was materially shortened. 

Resection of the Sympathetic for Epilepsy. — A.m.^t {Bull. 
Gen. de Ther., May 15, 1899) reviews the records of the 
cases of epilepsy which have been treated by resection of 
the cervical sympathetic, and shows that this operation is 
most unsatisfactory. While some apparent cures have 
been reported, in other instances the operation has re- 
sulted in an immediate increase in the number of epilep- 
tic seizures, and in some patients trophic disturbances 
have manifested themselves at a considerable lime after- 
ward. Hence the wise physician will keep to his treat- 
ment by bromid, which if it rarely cures, often benefits to 
a considerable degree, and never does serious injury. 

Treatment of Hematuria in Malaria. — WHITEHALL 
{New Orleans Med. and Surg, /our., ]une, 1 899) dis- 



144 



THERAPEUTIC NOTES. 



[Medical News 



putes the idea that quinin is not a good remedy in the 
treatment of hematuria occurring in malaria. He cites 
three cases in which he treated patients suffering from a 
severe form of malarial hematuria with large doses of 
quinin (60 to 80 grains in twelve hours) with prompt re- 
covery. There was no doubt that the hematuria in these 
cases was of malarial origin, and as the quinin was not 
given until after the blood appeared, it could not have 
been caused by the medicine, as has sometimes been 
claimed. 

New Method of Closing the Peritoneal Cavity. — O'Hara 
{Brit. Med. 'Jour., June 10, 1S99) treats the peri- 
toneal opening m the following manner : The incision 
through the peritoneum is never made more than four or 
five inches in length. If additional room is required the 
opening is stretched. As the membrane is very elastic 
it readily lends itself to this procedure. When the op- 
eration is over, a purse-string suture of kangaroo tendon 
is passed completely around the opening in the peri- 
toneum, beginning at the middle of the incision. When 
this is drawn up and tied the peritoneal cavity is perfectly 
closed against leakage from without, and there is no raw 
surface within to form adhesions to intestinal coils, etc. 
The suture is easily applied, and the peritoneum is in a 
far better condition to withstand any post-operative 
vomiting then after the ordinary suture. The remaining 
layers of the abdominal wall are closed by interrupted 
sutures. O'Hara has never seen any bad results follow 
this method of closure. 

Arsenic in Chorea. — As the pathogeny of chorea is 
very complex, the therapeutic indications are correspond- 
ingly variable. FfiRE ("Twentieth Century Practice", vol. 
X.). There is as yet no specific treatment. Among the 
factors entering into the production of chorea we must 
consider a nervous temperament, infection, shock, gen- 
eral debility, disturbed sleep, etc. When the chorea is asso- 
ciated with debility marked by anemia, general treatment 
is the best antispasmodic. Here arsenic has had and 
still enjoys a well-merited reputation, especially for chlo- 
rotic and lymphatic patients. It should be given in large 
doses, such doses being less dangerous than small ones, 
long continued. Arsenious acid, gr. ^^, increased by gr. 
TjL daily for children from eight to ten may be given, or 
Fowler's solution, from 5 to 8 drops a day for children 
and from 10 to 20 drops a day for adults, and gradually in- 
creased. Toleration will be facilitated by diluting the solu- 
tion with a tumblerful of either alkaline or acid carbon- 
ated water, which may be taken in two or three portions 
during the hour following meals, or if Fowler's solution 
is very badly borne by the stomach it may be admin- 
istered hypodermically in cherry-laurel water (to diminish 
the pain of the injection). The amount of the first injec- 
tion should be J,- c.cm. (53 m.), and this is increased 
by an equal quantity every day. Orarseniate of sodium 
may be used in rapidly increasing doses, gr. ,1.-, .^i^^, J^ 
daily for slight cases in children. In severe cases one 
may begin with gr. -jJ^- daily and increase the quantity 
by Jj gr. every day until gr. ss. is reached. After continu- 
ing us maximum for three days the quantity is again di- 
minished by -K gr. each day. Should treatment by the 



use of arsenic fail after twenty days it should be discon- 
tinued; otherwise it maybe kept up several days after the 
cessation of the movements. One must guard against 
arsenic poisoning. With this drug iron, cinchona, cod- 
liver oil, phosphate of lime, etc., may also be employed. 
Fere has not used antispasmodics (bromids, etc.) exten- 
sively in chorea, for the reason that he prefers to treat 
the general condition rather than the spasms. 

Treatment of Incontinence of Urine in Children. — (Thom- 
son, "Clinical Examination and Treatment of Chil- 
dren.") Much more benefit can be gained from the use 
of sedatives than either stimulating or tonic remedies. 
Of course, any physical cause, as phimosis, should be re- 
moved, and the child should not be allowed to drink any- 
thing after five or six o'clock m the afternoon. He 
should be awakened at eleven or twelve o'clock, and 
made to empty his bladder. Scolding or punishmg the 
child is of no avail, and should not be done. Bella- 
donna is the most valuable remedy, and should be given 
in large doses, so that the pupils should be moderately 
dilated and the throat be somewhat dry at bedtime. 
Twenty or 30 drops of the tincture may be given to a 
child four or five years of age at bedtime, and to an 
older child, from six to ten years of age, 30 drops 
may be given in the afternoon, and the dose repeated at 
night. If necessary this dose may be gradually in- 
C'eased up to a dram. If this should fail to prevent the 
wetting of the bed, the fluid extract of ergot, 20 drops 
three times a day, often gives good results. Tincture of 
nux vomica often is efficacious, especially when used m 
connection with belladonna. 

Treatment of Simple Conjunctivitis. — Ohlemann ("Oc- 
ular Therapeutics") in acute cases advises the use of cold 
compresses and the following lotion : 
5 Zmci sulphat. . . . . gt- i 

Aquas dest. . . . . 3 iv. 

Or 
5 Plumbi acetat. neutralis. . . §■"• i 

Aquas dest. .... 3 iiss. 

In chronic cases, in which the epithelium of the cornea 
is intact, 6 to 10 drops of a ij-per-cent. solution of lead- 
water in a wineglassful of boiled vi-ater should be ap- 
plied on compresses to the eye two or three times a day 
for fifteen muiutes at a time. The following ointment is 
very efficacious : 
IJ Hydrargyri oxidi flav. . . . gr. iii 

Vaselmi. ..... 3 iiss. 

When additional redness of the edges of the lids is 
present washes are sometimes not well borne. In such 
cases the following ointment should be used at night : 
5 Hydrargyri precip. alb. . gr. iii-ivss 

Zinci oxidi alb. . . . gr. ivss-viiss 

Aceti plumbi . . . gtt. iv-vi 

Vaselini . . . . 3 vi. 

In chronic^cases of an eczematous nature this ointment 

is useful : 

5 Ichthyol gr. J__.^ 

Amvlis / 

.,'•,■ aa . . . 3 iiss 

Zinc, oxidi ) 

Vaselini .... 3 vi-gr. xxv. 



July 29, 1899J 



COMPENSATORY THERAPEUTICS. 



145 



The Medical News. 

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SATURDAY, JULY 29, 1899. 



PUERPERAL FEVER; ITS BACTERIAL CAUSE 
AND SERUM-THERAPY. 

The deaths which appeal most to the physician 
are undoubtedly those which occur in child-bed. 
Despite our increased knowledge concerning the 
germ origin of the diseases which prove fatal during 
the puerperium we have not been able to entirely 
prevent the occurrence of puerperal fever. It had 
been hoped that streptococcic serum would prove of 
great service in the treatment of the disease, and in 
a certain number of instances it appears to have 
been efficacious, but on the whole its employment 
has been a source of keen disappointment. 

It has been assumed in thus trying streptococcic 
serum as a specific remedy, first, that puerperal 
fever is always due to a streptococcus infection, and 
secondly, that all micro-organisms that grow in 
chains and take the ordinary anilin stains belong to 
the same species. Neither of these assumptions is 
justified by the facts. Puerperal fever undoubtedly is 
sometimes due to other germs than to streptococci, 
and it is e.xtremely probable that the diphtheria 
bacillus sometimes plays a role in the etiology of the 



disease. At times there is perhaps a mixed infection 
by these germs, as in the throat, and unless care is 
taken in culture methods it might seem as though 
only the streptococcus were at work. In infections of 
the bladder the bacillus coli communis is so often 
the causative agent that one is tempted to wonder 
if it plays a role in uterine infections also. Adhe- 
sions between the uterus or adnexa and intestines 
often exist as a result of former inflammatory condi- 
tions, and by means of these the wandering of in- 
testinal bacteria like the bacillus coli is favored 
during the post-partum period, when extensive lym- 
phatic absorption occurs. In addition, at this time 
the uterine tissues are being dissolved in the body 
juices, and so furnish excellent culture material for 
the multiplication of micro-organisms. These facts 
would explain at the same time the origin of certain 
cases of so called idiopathic infection. The demon- 
stration of the bacillus coli in the process would be 
extremely important since recent work in France 
and Italy has shown that the manufacture of a seruir 
which is protective against its infection is possible. 
As to unity of species of all streptococci, that is 
largely an exploded idea. The hope of securing a 
specific serum depends on our finding some method 
of surely distinguishing the various forms of microbes 
that grow in chains. The prospect of successful 
serum-therapy of puerperal fever, then, depends on 
a more exact knowledge of the etiology of the dis- 
ease. In order to bring this about a large number 
of careful observations will be necessary. The aim 
is well worthy of the humanitarian sacrifice of time 
and labor on the part of every one interested in the 
reduction of mortality among the mothers of the 
land. 



COMPENSATORY THERAPEUTICS. 

It has been found in recent years that by judi- 
cious training the impaired functions of many organs 
ma)" be sufficiently restored to enable them to ac- 
complish for the individual organism practically all 
that is necessary. Graduated exercises, moderately 
and nicely adjusted hill-climbing, baths supplemented 
by judiciously resisted movements while in them, 
constitute a very helpful resource in the disturbed 
compensation of chronic heart trouble. Heart 
lesions do not disappear, and fatty and other degen- 
erative conditions of the heart muscle remain, but a 



146 



ECHOES AND NEWS. 



[Medical News 



lasting tone is often imparted to the muscular sub- 
stance of the heart and the arteries which enables 
them to do their work with much less difficulty and 
embarrassment than before. 

But cardiac therapeutics is not the only one to 
benelit by compensatory therapy. Urbantschitzch 
of Vienna has shown that by aural exercises many 
supposedly deaf children can be made to hear. He 
has demonstrated in a number of cases that the 
hearing faculty is seemingly only lying dormant for 
want of specific exercise. This exercise it has never 
secured because the sense of hearing in such people 
requires much more excitation than in the normal 
individual. If a special effort is made, however, it 
responds, and after patient training is able to catch 
many sounds that before escaped it entirely. The 
psychical element in hearing is trained to catch the 
faint inklings of sound that cOme wandering up 
through the defective hearing apparatus and that 
were previously neglected because of their indefinite- 
ness or absolute unmeaningness. This system of 
developing the faculty of hearing has been found to 
be effective also in certain cases of deafness due to 
disease, in which there is no gross lesion of the hear- 
ing apparatus. 

In tabes, Frenkel's system of exercises enables the 
physician to relieve to a great extent that most trou- 
blesome symptom of the disease, incoordination. 
To many ataxic patients who have been bedridden 
for years, walking on the streets, which for them 
had become either impossible or a torture because 
of their lack of confidence in themselves, becomes 
under this treatment not only easy of accomplish- 
ment, but a positive source of pleasure. Here, as 
in the case of the hearing exercises, the psychic ele- 
ment — the training of the attention — is an impor- 
tant part of the treatment, though it seems undoubt- 
edly true, also, that the impaired nerve paths learn 
by practice to carry more nervous impulses, and do 
it-more definitely than before. That exercise not 
overdone leads to increase of function, is a maxim 
that is of wide application in physiological processes, 
and that it holds good in the case of tabes seems not 
surprising. 

Similar beneficial results have been accomplished 
here in America in ocular therapeutics by corre- 
sponding methods. Patients who suffer from slight 
errors of refraction have been taught by judicious 



exercise of their accommodation to compensate for the 
refractive error, and after a time symptoms disap- 
pear even without the use of glasses. 

In pulmonary therapeutics exercises have always 
occupied a notable place, though it is true that of 
late years even more attention than formerly has 
been paid to them. 

It is evident, then, that we have in this principle 
of compensatory therapy a very valuable therapeutic 
measure, and one that deserves even more attention 
than has been given it. It is strictly in line with 
the most rational treatment of disease, since its only 
object is to aid nature, and that by the readiest and 
most direct means, viz., by guiding and increasing 
the functional efforts of the organism. Wherever 
psychic or muscular elements enter into a patient's 
pathological condition, training is capable of yield- 
ing excellent results. In hysterical and nervous 
affections it has been successfully applied in such 
methods as the rest cure. In purely mental disease 
training of the emotions can be most effective for 
the suppression of symptoms. In such associated 
psychical states as vertigo, the actual training given 
to dancers and acrobats may prove of service. In 
ailments that involve even unstriped muscular fibers, 
the modern therapeutics of gastric insufficiency and 
atonic constipation, massage, and electrization is ac- 
complishing much by stimulant exercise. 



ECHOES AND NEWS. 



Calmette' s Serum Effective. — The London T/ww of July 
2 1st contains a report from Allahabad of a well-authenti- 
cated cure, by the injection of Calmette's serum, of a 
snake-bitten patient who was in a state of collapse. 

Yellow Fever Decreasing in Mexico. — The Texas State 
Health Department received official advices from Mexico 
on July 2 1st that the yellow-fever epidemic in coast cities 
and towns is rapidly decreasing in severity. Quarantine 
has been enforced along the Mexican coast. 

More Nurses for the P/iilippines — Nine more trained 
nurses left New York City for the Philippines on July 
20th under the auspices of Red Cross Auxiliary No. 3 
for the Maintenance of Trained Nurses. When they ar- 
rive at Manila they will report to Miss Henshall, who 
will then have under her direction a corps of twenty-seven 
nurses. 

T/ie Plague at Europe's Doors. — The Paris correspondent 
of the Courrier des E/als Uitis states that the plague has 
appeared in Alexandria, which city is the key of Egyp- 
tian commerce. He dreads, therefore, that if quaraniine 



July 29. 1899J 



ECHOES AND NEWS. 



147 



and medical inspection are not instituted and vigorously 
enforced. Europe, through the principal Mediterranean 
ports, will become contaminated. 

Santiago's Epidemic /s Ended. — Noihwithstanding the 
fever epidemic, only si.xteen deaths were reported at San- 
tiago during the week ending July 19th. This is the 
lowest mortality the city has ever known. No new cases 
were reported after July 14th, and nearly all the patients 
in the hospitals are convalescent. General Wood will 
not lift quarantine, however, until all danger is past. 

4 Universal Language for Men of Science At a recent 

meeting of the Prussian Academy of Sciences, Professor 
Dills spoke of the need of a universal language for men of 
science. He considers Volapiik an artificial product of 
little use. English is his choice as the world- language 
because of its wide prevalence and because its simple 
structure and grammar make it eminently suitable for 
such use. 

Assistant Surgeon of the First California. — Dr. George 
H. Richardson of the class of '91, Medical Department of 
the University of Pennsylvania, who was sent to the 
Philippines on May 17, 1898, as acting assistant surgeon, 
has been appointed captain and assistant surgeon in the 
First California United States Volunteer Infantry. Dr. 
Richardson's experience has been a very varied one, he 
ha\-ing arrived from Burmah only a few months before 
sailing for Manila. 

A Physician Assaulted. — Dr. Robert P. Froehlich of 6i 
East 105th street, New York, was assaulted and kicked 
into insensibility on July 24th, by a gang of roughs 
because he had dressed the wound of a non-union motor- 
man belonging to the Second avenue street-car line whom 
they had maltreated. Though painfully injured, no 
bones were broken, and the physician hopes to be able to 
leave his house within a few days. Steps have been taken 
to apprehend his assailants. 

Asylum for insane Indians — The asylum for insane 
Indians at Canton, S. D., for which Congress made an 
appropriation of $42,000, with an additional S3000 for 
the purchase _of ground, will soon be erected. Out of a 
total of 250,000 Indians in the United States there are 
only 58 who are insane, i doubtful. 6 idiotic and 2 partly 
idiotic. It would seem, then, that the simple physio- 
logical life of the barbarian has some advantage over the 
brain- paralyzing e.xistence characteristic of civilization. 

Willard Hospital Inspected. — Among 2000 inmates of 
the Willard State Hospital thirty-four cases of diphtheria 
have been found. On July2isl the New York State 
Board of Health ordered a rigid quarantine of that insti- 
tution. The diphtheria has been of a mild type and no 
deaths have been reported. All the diphtheria patients 
are being treated with antito.xin, and immunization doses 
of the serum have been administered to many of the 
other inmates. Dr. .Macy and his assistants are attack- 
ing the disease systematically and effectively. 

Post for Army Consumptives Secretary Alger has ap- 
proved Surgeon-General Sternberg's recommendation that 



Fort Bayard, N. M., be set aside for the treatment of army 
consumptives. General Sternberg will immediately pre- 
pare to equip the post, from which some of the troops 
will be withdrawn to make room for patients. A compe- 
tent corps of surgeons will be assigned to duty there, but 
no special medicinal system will be followed, great reli- 
ance being placed on the benefits of the climate. It is 
proposed to transfer several patients to the new sanatorium 
from the Soldier's Home near Washington. 

The Tobacco-smoking Evil. — A writer in the German 
scientific periodical Prometheus declares that over-in- 
dulgence in tobacco will prove the ruin of South-Ameri- 
can peoples. Not only do children of two or three years 
smoke all day long, but mothers have been seen trying to- 
quiet their babies by putting cigars in their mouths. At 
the recent annual conference of the Lancashire and 
Cheshire branch of the British Medical Association Dr. 
J. Hilton Thompson propounded a new theo'y in respect 
to cigarette smoking. He showed the distinct presence 
of carbonic-oxid gas in tobacco smoke, and when inhaled 
from cigarettes, he said, it has the same injurious effect 
on the system as choke damp in collieries. 

A Prize for a Thesis on Army Rations Appreciative of 

the necessity for proper food for the men of the army and 
navy serving in tropical climates. Dr. Louis L. Seaman of 
New York City, late Major-Surgeon of the First Regi- 
ment, United States Volunteer Engineers, has offered 
through the Military Service Institute of the United 
States the sum of $100 in gold — or a medal of equal 
value as the successful competitor may elect — for the best 
thesis on "The Ideal Ration for the Army in the 
Tropics." This competition is open to commissioned 
medical and other officers of the army and navy, volun- 
teer and regular. All papers should be submitted before 
March i, 1900. The Board of award will be Colonel 
Weston, Acting Commissary General ; Lieutenant- Colonel 
Charles Smart, Deputy Surgeon- General, and Lieutenant- 
Colonel William E. Dougherty, Seventh United States 
Infantry. The headquarters of the Military Institute is 
at Governor's Island, New York Harbor. 

Queen Victoria's Family. — The Queen's family is now 
an exceedingly large one, how large can perhaps best be 
realized when the number of her direct descendants is set 
forth in tabular form: 

Queen j 

Sons and daughters living 7 

Gra-\dchildren 33 

Great-grandchildren 31 

Total 72 

Besides these direct descendants, the Queen has some- 
thing like 160 cousins and descendants of cousins. I 
they are counted with the Queen's own children, grand- 
children, and great-grandchildren, the members of the 
royal family are increased to not less than 230. The 
ages of the four generations of the royal family in the di- 
rect line of succession are : 

Queen So 

Prince of Wales 55 

Duke of York 34 

Prince Edward of York 5 

— London Ne-MS. 



148 



MEDICAL MATTERS IN NEW YORK. 



[Medical News 



The ■ 'Kissing Bug." — "This and other papers are record- 
ing daily the sufferings of people who think that they 
have been bitten by a newly invented insect. That the 
bites are inflicted by something is probably true, and 
there is no doubt at all about the tumefaction and the 
pain which the doctors are called upon to reduce and as- 
suage, and yet there is not the faintest evidence to show 
either that a strange msect has made its appearance in 
the couniry or even that some familiar one has become 
more fierce and venomous than usual. The entomologists 
unite in denying the existence of a 'kissing bug,' and 
though little creatures by the dozen of one sort or another 
have been submitted to these authorities as criminals 
caught in the very act of osculatory attack, still the 
learned ones refuse to be convinced, and not only give 
the accused names as ancient as they are long, but assert 
and, if need be, prove that the incriminated bugs couldn't 
bite if they would, and wouldn't if they could. The whole 
trouble seems to be the effect of misguided and over- 
exerted imaginations. Charlatans of the species that has 
received general mention once or twice in this column 
claim that all, and occasionally demonstrate, that a few 
bodily ills can be cured by 'faith.' This 'kissing bug' 
epidemic tends to show that 'faith' can cause functional 
disturbances as well as remove them. But everybody 
knew that before." — A'ew )'ork Times. 

Railtvay Accidents in the United States. — The Inter- 
st.ue Commerce Commission makes the following report 
for the year ending June 30, 1898 : The total number of 
casualties to persons on account of railway accidents dur- 
ing the year ending June 30, 1898, was 47.741. The 
aggregate number of persons killed as a result of railway 
accidents during the year was 6859, and the number in- 
jured was 40,882. Of railway employees, 1958 were 
killed and 31,761 were injured during the year covered 
by this report. With respect to the three general classes 
of employees, these casualties were divided as follows : 
Trainmen, 1141 killed, 15.645 injured; switchmen, flag- 
men, and watchmen, 242 killed, 2677 injured; other em- 
ployees, 575 killed, 13,439 injured. The casualties to 
employees resulting from coupling and uncoupling cars 
were, persons killed, 279; injured, 6988. The corre- 
sponding figures for the preceding year were, killed, 214; 
injured, 6283. 

The number of passengers killed during the year was 
221 and the number injured 2945. Corresponding figures 
for the previous year were 222 killed and 2795 injured. 
In consequence of collisions and derailments 72 passen- 
gers were killed and 11 34 passengers were injured during 
the year embraced by this report. The total number of 
persons, other than employees and passengers, killed, 
was 4680; injured 6176. These figures include casual- 
ties to persons classed as trespassers, of whom 4063 were 
killed and 4749 were injured. The summaries contain- 
ing the ratio of casualties show that i out of every 447 
employees was killed and i out of every 28 employees 
was injured. With reference to trainmen — including in 
the term enginemen. firemen, conductors, and other 
trainmen — it is shown that i was killed for every 150 
employed and i was injured for every 11 employed. 



One passenger was killed for every 2,267,270 carried and 
I injured for every 170,141 carried. Ratios based on 
the number of miles traveled, however, show that 60.542- 
670 passenger-miles were accomplished for each passen- 
ger killed and 4.543.270 passenger-miles accomplished 
for each passenger injured. 



MEDICAL MATTERS IN NEW YORK . 

A NEW CURE FOR INSOMNIA — MATCHE.S IN TEA, A 
NEW DELICACY FOR CON VALESCENTS— BELLEVUE'S 
ACROMEGALY PATIENT DEAD— MORE TETANUS — 
THE ACTIVE CHRISTIAN-SCIENCE "HEALERS ' — THE 
BABIES' HOSPITAL SUMMER BRANCH — THE HEALTH 
DEPARTMENT AND ITS NEW QUARTERS — YELLOW- 
FEVER PATIENTS DISCHARGED. 

We have heard of the man who carried a hot brick in 
his pocket to keep his feet vi'arm, but never until now of 
one who attempted to woo the goddess of sleep by inhal- 
ing illuminating-gas. A painter, forty-two years of age, 
residing in Ludlow street, is the latest aspirant for fame 
in this particular line, and that the sleep induced by this 
method of treatment did not continue for all time was due 
only to the opportune discovery of his condition by a police 
officer. To the magistrate before whom he was haled the 
painter explained that he had found this original recipe 
for insomnia in a newspaper, and had determined to give 
it a trial. 

Bellevue Hospital must have its periodical sensation. 
This time it is due to the accidental introduction into one 
of the male convalescent wards of a new beverage, the 
popularity of which, however, appreciably waned after the 
first draught. It all happened in thiswise: A few days 
since an attendant brought a vessel containing a gallon of 
hot tea from the hospital kitchen and placed it on a table 
in the ward preparatory to its distribution to the patients. 
While his attention was momentarily distracted, one of 
the patients, in reaching for a glass on the table, over- 
turned a box of matches into the tea. Another attendant 
started in to distribute the nectar, but noticing the matches 
floating about in it, decided that a combined woodpile 
and weak-tea diet might not be exactly the fuel the con- 
valescents most needed, and so fished them out, but on 
general principles being opposed to unnecessary -waste 
and all unconscious of the fact that the phosphorus had 
been dissolved off the matches, proceeded to ladle out the 
tea. It was not long before there was a sound not ex- 
actly of revelry by night, and liberal use of emetics and 
of stomach-tubes was necessary before the ward was re- 
stored to its accustomed matchless equanimity. Fortu- 
nately no lasting ill effects resulted from the radical de- 
parture from old-time methods, and in future the tea 
will be served in the regulation way. without frills or 
addenda. 

Then, too, Bellevue has lost its star patient, and great 
is the regret thereat. Mary Fogarty, fifty-one years of 
age, who was affectionately and widely known to her 
friends and neighbors in West Sixtieth street as "Big Nose 
Mary, "died on the afternoon of July 21st from acromegaly. 
Common report has it that she was the first patient 
ever received at the hospital suffering from this disease. 



JULV 29, 1899J 



MEDICAL MATTERS IN CHICAGO. 



"49 



although this statement has not been officially confirmed. 
She weighed nearly three hundred pounds at the time of 
her death, was nearly, if not quite six feet in height, and 
wore a heavy beard and mustache. Her hands, feet, and 
nose especially showed the «dvanced stage of the disease 
with which she was afflicted, all being enlarged to enor- 
mous proportions. 

Tetanus antito.xin has again been tried and found want- 
ing, which, perhaps, is not surprising as it has met this 
fate so often in this vicinity during the past two weeks. 
Guiseppi Consumanno, fourteen years old, while patriot- 
ically celebrating the Independence anniversary of the 
land of his adoption, ploughed a furrow on one of his 
hands with the assistance of a pistol and a small caliber 
bullet. Ten days later symptoms of tetanus developed, 
and on July i6th the boy was admitted to the Columbus 
Hospital. Antitoxic serum was injected, and every effort 
made to save his life, but he died on July 22d. This is 
the twenty-first death from tetanus that has occurred in 
and about the city since the Fourth of July, and all can 
be traced directly to wounds inflicted by firearms or 
fireworks on that day. 

The medical and lay press devote columns to ridiculing 
the claims of Christian-Science "healers," and yet this 
sect goes merrily on its way contributing to the mortality 
records. A certain Mr. Robertson, seventy-eight years 
old, formerly a well-known artist, was the latest victim 
in this city. His ailment was said to be gastro-enteritis, 
and he was ill but twenty-four hours. His daughter, a 
•'first reader," or it may be "primer," in the First 
Christian Science Church of Orange, N. J., believing 
prayer to be more efficacious than bismuth under such 
circumstances, administered the former in large doses, with 
the result that after the lapse of the number of hours above 
mentioned no further treatment was necessary. Funeral 
services were held on the 25th inst. 

The managers of the Babies' Hospital at Fifty-fifth 
street and Lexington avenue, on July 22d opened a new 
hospital building at its summer branch settlement at 
Oceanic, N. J. It contains an entirely ne.v feature — two 
private wards in which sick babies from the hotels and 
cottages of the surrounding summer resorts can be treated. 
Heretofore the hospital has accepted free patients only, 
mostly from New York's tenement-houses, but the man- 
agers have been so besieged for private treatment by 
summer frequenters of the resons nearby, that they have 
decided upon this departure. Only children under three 
years of age are accepted in the free wards, but none suf- 
fering from contagious disease. Their stay at Oceanic 
is not limited, but all are cared for while they need sea 
air and country living. 

The ordinance recently offered at a meeting of the 
Board of Aldermen to forbid the sale of cigarettes to boys 
under eighteen years of age has been reported favorably 
by the Law Committee, to which it was referred, and will 
be acted upon at the next meeting. 

Between 350 and 400 tons of records are now being 
moved from the present quarters of the Board of Health 
in the Criminal Court building in Centre street to its new 
home in the building at Si.xth avenue and Fifty- fifth street, 



which was formerly occupied by tne New York Athletic 
Club. The Health Board was organized in i865, just 
after a cholera panic, and was first located in the Police 
building at Mulberry and Mott streets. Five years ago 
it moved into the quarters it is now leaving, where it has 
always had an uncomfortable existence because of the 
prejudice of the other departments of the city to its pres- 
ence among them. It will now enjoy a sort of "splen- 
did isolation" in a part of the city where it will be more 
accessible to the medical profession. Almost every year 
some new duty is added oy the Legislature to its work, 
and backed up as it is by law and by police of its own, 
it is a very powerful safeguard of the public health. Its 
Bureau of Vital Statistics records each year the deaths of 
50,000 people and the births of as many others. In the 
Sanitary Bureau there are five divisions — of general and 
sanitary inspection, of contagious diseases, of medical 
sanitary inspection, of inspection of foods, offensive trades 
and mercantile establishments, and of school inspection; 
and there is a pathological and bacteriological division. 
The staff of officers consists of the president, three com- 
missioners, the secretary, counsel, seventeen honorary 
consulting officers, and twelve salaried executive officers. 
There are nearly 800 employees in the main office, and 
the 4 branch borough offices, including 96 sanitary 
policemen. Its expenses are between eleven and twelve 
hundred thousand dollars a year and it has an income of 
about $3000 from the sale of vaccines and antitoxins 
and from transcripts of records. 

Miss L. C. Clendenin, who has been ill with yellow 
fever and quarantined on Hoffman's Island since her ar- 
rival here on the transport "McClellan" from Santiago 
on July 6th, has entirely recovered and been discharged. 
Mr. Oscar L. Lackey of Baltimore, the other patient from 
the transport, who was inoculated with antitoxin serum 
under the supervision of Health Officer Doty, has also re- 
covered and left for his home. 



MEDICAL MATTERS IN CHICAGO. 

MISSISSIPPI VALLEY MEDICAL ASSOCIATIO.V — INCOR- 
PORATION OF THE ILLINOIS SOCIETY FOR THE PRE- 
VENTION OF CONSU.MPTION — VOLUNTEER PHYSI- 
CIANS AS MEDICAL INSPECTORS — RESOLUTIONS 
ADOPTED BY THE STATE BOARD OF HEALTH — 
BEQUESTS OF DR. ROBERT L. REA. 

According to a preliminary announcement the 
twenty-fifth annual meeting of the Mississippi Valley 
Medical Association will be held in this city Ooiober 3, 
4, 5, and 6, 1899. This is the first time the Association 
has held its meeting in Chicago, and the local profe son, 
under the leadership of Dr. Harold M. Moyer as Ciair- 
man of the Committee of Arrangements, has provided 
many attractions for the visiting doctors. Among them 
may be mentioned an attractive program in both medical 
and surgical sections, and special clinics in all the de- 
partments of medicine and surgery, to be given at the 
various hospitals and colleges before and after the 
meeting. 

The occurrence of the autumn festival at this time is an 
added attraction. The President of the United States 



150 



MEDICAL MATTERS IN CHICAGO. 



[Medical News 



and his Cabinet, Admiral Dewey, the Premier of Canada, 
and President Diaz of Mexico have signified their inten- 
tion of being present. The railroads have promised a 
one-fare round-trip rate, with a liberal limit to tickets. 
The Committee of Arrangements will issue a souvenir 
program which will also be the official program, 
to the number of 35,000, to be sent to every 
doctor in the Mississippi Valley and territory contribu- 
tory to Chicago In addition to the program of the meet- 
ing this will contain a schedule of clinics and a sketch of 
medical Chicago. Dr. Duncan Eve of Nashville, Tenn., 
is president, and Dr. Henry E. Tuley of Louisville, Ky., 
secretary of the Association. 

The Illinois Society for the Prevention of Consumption 
has been incorporated by Drs. Frank W. Reilly, Henry 
B. Favill, and Mr. Joseph Hughes. 

Our City Health Commissioner, Dr. Arthur R. Rey- 
nolds, has issued a call for volunteer physicians to serve as 
medical inspectors, and more than forty have been 
enrolled upon the books of the department to undertake 
the house to-house canvas for the purpose of dissemma- 
ting knowledge as to the care of infants and to inspect 
sanitary conditions. It is intended by the department 
that the work shall not be interpreted as being of a char- 
itable nature ; the physicians are not required to prescribe 
or perform medical service except in cases of emergency. 
In the first place, the object is to instruct mothers and 
those in charge of infants and children during the hot 
weather as regards hygiene of the young, their feeding, 
clothing, bathing, and care, with a view to the preven- 
tion rather than the cure of disease. Secondly, the ob- 
ject is the correction of sanitary defects and the abate- 
ment of nuisances prejudicial to the health of adults and 
children alike. The work of the Health Department in 
a city l-.ke Chicago is necessarily vast in us possibilities, 
and especially inviting to medical students who may wish 
to become experts in bacteriologic or other research. For 
this reason the plan of Commissioner Reynolds to increase 
his office force without expense to the city by admitting 
recent graduates of medical colleges to the Department 
Laboratory is to be commended. Of course facilities can 
be furnished for only a limited number, but this is an ad- 
vantage, as it gives wide opportunity of selection. It is 
stated that 2623 bacteriologic examinations were made 
last year, and 2635 examinations of water, ice, milk, 
vaccine, lymph, butter, etc., and 30,000 other examina- 
tions of ice cream, cheese, and the like. In making tests 
of tills kind medical students with a little training will be 
able to do efficient work and thus add greatly to the value 
of the department, while at the same time securing excel- 
lent drill in the important province of preventive med- 
icine. 

At the July quarterly meeting of the State Board of 
Health, held in this city, the following resolutions were 
adopted by the Board : 

Whereas, Section 2, of an Act to Regulate the 
Practice of Medicine in the State of Illinois, and to repeal 
an Act named therein, approved April 24. 1899. in force 
July I, 1899, gives the State Board of Health discretion- 
ary power as to granting certificates to graduates of le- 



gally chartered medical colleges in Illinois in good stand- 
ing as may be determined by the Board, and. 

Whereas, It is evident, notwithstanding the discre- 
tionary power given the Board, that the true intent and 
purpose of this Act is to require all persons to prove their 
qualifications to the State Board of Health by passing an 
examination ; therefore, be it 

Resolved, That all applicants for a State certificate to 
practise medicine and surgery in the State of Illinois, 
who are graduates of medical colleges in good standing, 
as may be determined by this Board, shall, before re- 
ceiving a certificate, be obliged to pass an examination 
such as contemplated in Section 2, of an Act to Regulate 
the Practice of Medicine in the State of Illinois, in force 
July I, 1899. 

Resolved, That the phrase "medical college or insti- 
tution in good standing," in the first paragraph of Section 
2, of the Act to Regulate the Practice of Medicine in the 
State of Illinois, in force July i, 1899. is hereby defined 
to include only legally organized, properly conducted 
medical institutions, having a sufficient and competent 
corps of instructors and ample facilities for teaching, dis- 
sections and ambulatory and hospital clinics, which conform 
to the requirements relative to the preliminary education 
of matriculants, the course and period of study, the num- 
ber, character, and length of lecture terms, the duration 
of attendance on hospital and clinical instruction, which 
obtain in the majority of medical colleges in the United 
States. 

The Illinois State Board of Health, however, will not 
consider in good standing after January i, 1900, any med- 
ical institution which does not require of all students (ex- 
cepting graduates of reputable colleges of arts and 
sciences, or reputable colleges of dentistry, pharmacy, or 
veterinary medicine, to whom one year's advanced stand- 
ing may be granted), as a condition of graduation, an 
attendance of four full courses of lectures of at least six 
months each, in four separate years, no two courses com- 
mencing or ending in the same calendar year of time. 

Resolved, That no medical college issuing a cata- 
logue of announcement in which are contained misrepre- 
sentations respecting its teaching, clinical or hospital facil- 
ities, its faculty, or its courses of study, or false 
representation as to the number of students matriculated 
or in attendance, will be regarded as in good standing. 

Dr. Robert L. Rea, who died July loth, bequeathed 
to the Northwestern University at Evanston Si 0,000 with 
which to endow the Department of Anatomy, which shall 
be known as "The Rea Professorship of Anatomy." The 
College of Physicians and Surgeons, of which the de- 
ceased was a faculty member nearly twenty years, re- 
ceives $5000, to be devoted to the educational expenses 
of worthy and indigent students. The bequests to the 
Norihwestern University and to the College of Physicians 
and Surgeons are direct and made payable inside of three 
years after the death of Dr. Rea. 

For Leucorrhea — D a lche claims good effects from the 
use of tampons soaked in a mixture of lactic acid, 3 parts, 
and glycerin, 100 parts, which he first tried in the belief 
that lactic acid is the natural agent for vaginal antisepsis. 



July 29, 1899] 



OUR LONDON LETTER. 



'51 



CORRESPONDENCE. 



OUR LONDON LE TT£R. 

[From Our Special Correspondent.! 

POISON BY POST AND THE INSANITY PLEA— CANCER 
DELEGATE TO AMERICA — ANOTHER CAUSE OF CAN- 
CER— CLIFhORD ALLBUTT'S POLYCLINIC LECTURE — 
SIR WILLIAM HENRY FLOWER — UNIVERSITY EXTEN- 
SION WORK IN MEDICINE — THE MEDICAL DEFENSE 
UNION. 

London, July 16, 1899. 

English justice has a grim way of "arriving" with 
surprising promptness. The girl, Mary Ansell, whose 
callous cruelty in poisoning her imbecile sister for the 
sake of her insurance money, by means of a cake 
sent by mail, containing phosphorus paste, we referred 
to some three months ago, was put on trial last week. 
She was found guilty and condemned to death inside of 
forty-eight hours, and was duly hung to day. A petition 
was presented to the Home Secretary, urging that several 
of her family were mentally defective and that the girl 
herself was probably insane, but as it was overwhelmingly 
proved at the trial that the prisoner had deliberately taken 
out an insurance policy on her sister's life without her 
knowledge, then tried twice to poison her, once unsuc- 
cessfully by means of a package of tea, and that she 
wanted the money in order to enable her to get married, 
as her fiance and even she herself admitted ; a lunatic 
capable of that degree of ingenuity and calculation would 
be a criminal monster, which any community would be 
justified in hanging in self-defence, and the petition was 
therefore refused. 

Exit consumption, enter cancer. The Cancer Society 
of London has despatched an envoy. Dr. Arthur Duffy, 
to the United States to study the American methods of 
investigating the disease, and especially those of the New 
York State Cancer Laboratory at Buffalo, under the 
direction of Dr. Roswell Park. The society's chairman. 
Sir Charles Cameron, M.P., has announced his intention 
of moving in Parliament for the appointment of a royal 
commission to investigate the alleged alarming increase 
and for the collection of information bearing upon the 
causation and methods of prevention of the disease. 

Dr.Lambert Lack's announcement that he has discovered 
the cause of cancer in certain disturbances of the basement 
membrane of epithelium, by imitating which in the lower 
animals he has succeeded in producing cancerous growths, 
is read with considerable scepticism. It recalls too vividly 
the old "isolation" or "strangulation" theory of Cornil, 
according to which under-proliferation of the connective 
tissue was the starting point, by cutting off buds or 
islands of epithelium which once isolated set up reproduc- 
tion on their own account. However, all will await the 
publication of the theory and its details in the regular 
journals with interest. No further details have yet been 
received from "Dr. Bra of Paris" since his preliminary 
announcement of the discovery of the "cancer germ " in 
the daily papers a couple of months ago. 

Professor Clifford Allbutt of Cambridge lectured last 
week before the members of the London Polyclinic on 



"Cerebral Syphilis." This was the first of a series of 
single lectures or short courses of lectures by distinguished 
members of the profession, both of London and the Prov- 
inces. The work at the Polyclinic will probably be sus- 
pended during the month of August, at the close of the 
present (second) term of lectures and demonstrations. 

The death of Sir William Flower, the distinguished 
zoologist, has brought to mind the well-nigh forgotten 
fact that he was originally an active member of our pro- 
fession. He was a regimental surgeon all through the 
Crimean War and anatomist and assistant-surgeon at 
Middlesex Hospital for several years after that. Then 
for twenty-three years he was Curator of the Museum of 
the College of Surgeons and for five years Hunterian 
Professor of Comparative Anatomy in the College, so 
that although he early retired from actual practice he was 
intimately connected with the science and teaching of 
medicine during the greater part of his career. Flower 
was no giant or discoverer, although he belonged to a 
generation of such, but he has left behind him a mass of 
excellent and most valuable work. He was one of the 
greatest museum-arrangers, administrators, and in the 
best sense "popularizers" that England has known. 
The sacred traditions of the Hunterian Museum hardly 
gave him a fair opportunity, although he did much for 
the collection and toward its rationalization, but the 
Natural History Department of the British Museum, 
South Kensington, became in his hands, one of the model 
museums of the world, not merely a superb collection, but 
one great illustrated manual of zoology, the pages of 
which even he who runs may read. No American physi- 
cian visiting London can afford to miss spending a day 
in this spiendid monument of the genius and organizing 
skill of one of our colleagues. 

An interesting experiment of medical university exten- 
i sion work has just been tried with great success in Ches- 
ter. The medical men of that city and the adjacent 
towns formed a class and invited Dr. Sheridan Delepine, 
Professor of Pathology in Owens College, Manchester, to 
deliver a course of lectures on bacteriology. These have 
been well attended and greatly enjoyed, and the plan is 
to be extended to other subjects and in other districts. 

The Medical Defense Union is coining golden opinions 
in the profession by its efficiency and vigor in defend- 
ing suits for malpractice brought against its members. 
Dr. Woodley Stocker writes to the Laticei to express 
his appreciation of the inestimable value of its assistance 
in winning a suit of this description brought against him 
in connection with an injured hand. The value of legal 
counsel with training and experience in this class of cases, 
the relief from the most crippling part of the expense, 
and above all the feeling that you have at your back an 
organization representing the entire profession are worth 
everything to the victim of one of these suits. Usually 
he feels that he has the sympathy of the profession — but 
must fight alone and pay all the costs himself, and that, 
too, in a trial from which the utmost he has to hope is an 
acquittal, which probably half the community will persist 
in regarding as a miscarriage of justice. 

The London School Board has reappointed Dr. C. E. 



152 



TRANSACTIONS OF FOREIGN SOCIETIES. 



[Medical News 



Shuttleworth and Dr. May Dickinson Berry for another 
year to continue their admirable work in e.xamining de- 
fective children and advising as to the best methods of 
their education. 

The annual meeting of the Jenner Institute has just 
been held and much enthusiasm was manifested at the 
encouraging prospects opened up by Lord Iveagh's superb 
donation. The work of the past year was reported as 
satisfactory and the plans for the future outlined. These 
are far-reaching, and include reseach work in compara- 
tive pathology. 



TREATMENT OF TETANUS BY OPIUM. 

To the Editor of the MEDICAL News. 

Dear Sir: — Mr. J. F. and grandson were unloading 
wheat one afternoon at 5 o'clock. The old gentleman 
reached for a sheaf, and at the same moment his grand- 
son who was looking the other way, ran the tine of a 
pitchfork into the back of the middle finger of his right 
hand near the metacarpophalangeal articulation. The 
wound caused great pain, which became agonizing at 
8 P.M., at which time I was sent for. I found the pa- 
tient livid and gasping for breath. The pain had ex- 
tended up the arm and to the neck, chest, and heart, the 
jaws being stiff. One dram of pulverized opium was put 
in a basin, a pmt of boiling water poured on it, and the 
injured hand being held over the basin, the hot liquid was 
poured on it with a tablespoon. When a half dozen 
spoonfuls had been applied the patient experienced won- 
derful relief. I continued the application for perhaps 
half an hour, reheating the opium solution several times, 
and during the night several applications were also made, 
but no further trouble occurred, and the next day the pa- 
tient was well, with the exception of some soreness about 
the hand. 

Since then a lady came to see me in regard to her 
foot which had been mjured by treading on a rusty nail 
two days before. She had suffered great pain, and some 
stiffness of her jaws was present. When the wound was 
touched a shock seemed to go through her whole body. 
A pint of the opium solution was prepared, and her foot 
immersed in it, the solution being as hot as could be 
borne. In half an hour the patient expressed great re- 
lief. She followed this treatment occasionally for several 
days, and the symptoms entirely disappeared. 

I have treated some half dozen cases of injury of the 
hands and feet m the same way, with perfect relief in 
each case. I learned the use of the infusion of opium 
from the late Professor Nathan R. Smith, while a student 
at the University of Maryland from 1866 to 1S69. It 
was a favorite prescription with him, and has been like- 
wise with me. I had always used it either warm or cold. 
The extreme illness of Mr. F. made cooling of the liquid 
impossible, and thus I accidentally became acquainted 
with the virtues of the hot infusion of opium. Recent 
reports of fatal cases of tetanus following slight injuries 
has prompted the writing of this letter, and I hope that 
other physicians may have equal success with the above 
treatment. John J. Ligget, M.D. 

I.ADIESBURG, Md., July 19, 1S99. 



TRANSACTIONS OF FOREIGN SOCIETIES. 

British. 

COMMUNICABLE MALARIAL FEVER — REMOTE 'PROG- 
NOSIS OF PERICARDITIS — HVDRAMNION IN CASES OF 
HOMOLOGOUS TISSUES — UNSUCCESSFUL NEUROR- 
RHAPHY — A DISCUSSION ON COXA VERA IN ADOLES- 
CENCE. 

The Royal Medical and Chirurgical Society, June 13th, 
listened to a paper by Rogers on the eradication of 
Assam epidemic malarial fever. His view was that this 
is an intensified form of malarial fever, which after a suc- 
cession of very unhealthy years, has attained the power 
of being slowly communicable, usually in an indirect 
manner, from person to person. The success of his rec- 
ommendations for the eradication of the disease has con- 
firmed this opinion as to its nature. These recommenda- 
tions were, briefly, as follows: (i) All newly imported 
coolies should be placed in fresh lines and not allowed to 
enter old infected ones; (2) in slightly infected lines all 
infected persons, together with their households, should 
be moved out into separate segregation lines and the huts 
which they have inhabited should be burned and not re- 
built; (3) in badly infected lines all the healthy people 
should be moved out during the dry cold weather months 
when infection is at a minimum and placed in new 
lines, while the infected persons and their households 
should be segregated and the infected line abandoned. 

Secjueira read a paper on the remote prognosis of peri- 
carditis. Recent work seems to show that the pericar- 
dium acts as a support to the heart during muscular exer- 
tion. If the pericardium is softened and dilated by 
inflammation this support may be lost, and under severe 
strain the chambers of the heart may therefore dilate at 
once. If the pericardium becomes dilated and adherent 
to the chest wall the effect on the heart of working in a 
dilated sac may become evident in the direction of lack of 
compensation. If the pericardium is adherent but not 
dilated the effect will be small. Clinically the 100 cases 
which he had examined fell into three groups: (r) those 
in which there was perfect compensation of the heart ; (2) 
those in which compensation was easily broken ; and (3) 
those in which compensation never occurred. In the 
first group there were thirty-one cases. All the patients 
were more than fourteen years of age. The pericardium 
was undilated : there were no symptoms and practically 
no physical signs. In the second group there were 
eighty-six cases. The young patients, and especially 
young females, formed the bulk. There were all grada- 
tions in the severity of the symptoms. Many of the pa- 
tients were in and out of hospital for years, while in some 
compensation occurred once only. In the young females 
(from six to fifteen years old at the time of the acute at- 
tack) death occurred on the average in hltle over two 
years. In the males, in whom the original attack oc- 
curred between the same ages, the average length of life 
was 3 ^ years. The extremes were, of course, very wide 
of this. In the fatal cases the pericardium was found to 
be dilated and adherent and the severity of the symptoms 
depended in a great measure upon the amount of the 
dilatation. Sequeira had found an interesting re- 



July 29 1899] 



NORTHWESTERN MEDICAL AND SURGICAL SOCIETY. 



153 



lation between the annual increase in the body weight 
and the age at w'hich death took place in the cases in 
which the acute attack occurred in early childhood. In 
the third group of cases, thirteen in number, compensa- 
tion was never complete. In some this depended upon 
the fact that the dilatation of the pericardium was pro- 
gressive. The patients were all young and death resulted 
in from three to nine months after the acute attack. The 
effect of concomitant valvular disease and of myocar- 
ditis was considered and Sequeira concluded that valvular 
lesions were of little moment in many cases and that 
myocardial degeneration could not induce the enormous 
dilatation of the heart so often observed if the pericar- 
dium were undilated. Further, the amount of hyper- 
trophy of the heart in cases of adherent pericardium ap- 
peared to be in the main dependent upon the amount of 
dilatation of the cardiac envelope. Sequeira concluded 
that he had proved that the amount of dilatation of the 
pericardium must be taken into account in the considera- 
tion of the remote prognosis of acute pericarditis and that 
influences, such as the increase in the body weight and 
the amount of muscular exertion, which augment the la- 
bor of a heart working in a dilated pericardium, tend 
to impair the power of compensation. 

At the Obstetrical Society, June 17th, Wilson spoke 
of hydramnion in cases of unioval or homologous twins. 
Although twins derived from separate ova are nearly seven 
limes more frequent than those derived from a single 
ovum, hydramnion apparendy occurs about as frequently 
in one class as in the other. The paper was founded on 
two cases which occurred in his own practice, and on 
twenty others which he had collected. The history of a 
case of this kind is that the patient, usually a multipara, 
at the fourth or fifth month and without any assignable 
cause undergoes rapid enlargement of the abdomen, 
which in the course of a few days or weeks leads to ex- 
treme distress from the pressure. The affection ends in 
nearly every case in spontaneous delivery before the end 
of the seventh month, although in about twenty percent, 
labor has to be induced. The contents of the uterus are 
found to be twin fetuses of the same sex, one of which 
is decidedly larger that the other, and is enclosed in an 
amnion containing an enormous excess of fluid. There 
is a single placenta common to the two fetuses, a single 
chorion, and two amnia. The heart and kidneys of the 
larger fetus are hypertrophied, often enormously. Neither 
fetus shows any malformation and the mother is healthy. 
The cause of the hydramnion is found in the relation of 
the vessels of the two fetuses to the common placenta. 
The twin whose vessels run a shorter or more direct 
course obtains an undue share of blood from the placenta, 
in which anastomoses take place between the vessels be- 
longing to the two fetuses. In this way one fetus grows 
faster than the other and the heart of this one becomes 
not only absolutely but also relatively larger than that of 
the other. This leads to an increased secretion from the 
kidneys, and possibly from the skin and the placenta. 
The appropriate treatment is the induction of premature 
labor by puncture of the membranes. 

At the British Orthopedic Society, May 27th Thomas 



showed a patient in wiom the left popliteal nerve had 
been injured by a kick from a horse, and talipes equino- 
varus had followed. Neurorrhaphy having failed, tarsec- 
tomy was performed with an excellent result. 

Tubby said that it is difiicult or impossible to restore 
a nerve by suture when the division has occurred at or 
near the point where the nerve breaks up into branches. 
He further described a case occurring in his own practice 
in which spastic hemiplegia with flexion of the elbow and 
wrist and pronation was treated by open section of the 
flexor tendons, especially the flexor carpi radialis, and de- 
tachment of the pronator radii teres from its insertion. A 
hole wis made in the interosseous membrane and the 
tendon was passed round the back of the radius to its 
outer border and fixed, thus reversing the action of the 
muscle. The wrist was kept midway between fle-xion and 
extension by means of splints. In six weeks the patient 
could pick up a pin. 

Keetlv opened a discussion on coxa vara. He de- 
scribed types of the two chief varieties which commence 
in adolescence. The deformity is rachitic in origin. The 
partial or even total absence of rachitic changes in other 
parts is no disproof of this, as the older the patient the 
more localized do rachitic changes tend to be. The vari- 
ous modes of osteotomy which had been carried out or 
proposed, including a new method, were described. In 
theory the neck of the bone should be operated on ; in 
practice the trochanteric region is more convenient. 
Decreased angle of the neck and shaft forms the striking 
feature at a first glance at the deformity, but the main 
crianges are in the neck itself, especially near the head. 
In fact, coxa vara is a rachitic deformity of the upper epi- 
physeal region of the femur. The deforming influence 
sometimes extends far down the shaft. Compensatory 
genu valgum is common. The speaker called attention 
to a peculiar expansion of the facial bones, giving prom- 
inence to the eyeballs and width and flatness to the upper 
half of the face. Coxa vara in cases of early rickets is 
very common, but cases during adolescence are rare. 
The commencement of the flood of modern literature on 
the subject dated from his own paper in the Illustrated 
Medical News of September 29, 1888. The hip-joint is 
healthy in these cases. For this and for other obvious 
reasons excision is not justifiable. 

Little found great difficulty in accepting the theoiy that 
late rickets is the cause. In none of the extremely rickety 
skeletons in the London museums is anything approach- 
ing the deformities depicted by Kocher and others found. 
It seems to be a process sui generis. Charpentie had 
shown that osteitis may cause the deformity. 



SOCIETY PROCEEDINGS. 



NORTHWESTERN MEDICAL AND SURGICAL 
SOCIETY OF N EW rORK . 

Stated Meeting, Held March /j, iSgg. 
The President, William Stevens, M.D., in the 
Chair. 

SCURVY ASSOCIATED WITH MEMBRANOUS COLITIS. 

Dr. J. H. Fruitnight: I have recently had under 



154 



NORTHWESTERN MEDICAL AND SURGICAL SOCIETY. 



[Medical Nets 



observation a case of scurvy occurring in a boy, eight 
years of age, the child of wealthy parents. He had 
been allowed to eat a great deal of salt meat and salt 
smoked fish, these forming his principal diet, for he 
would not eat potatoes or any other vegetables. 
The disease showed itself first by pain about the joints, 
particularly near the knees, ankles, and wrists ; ecchy- 
motic spots also appeared in the neighborhood of these 
joints. The gums soon became spongy and bled easily. 
Child also complained of great pain over the region of the 
descending colon which seemed to indicate some intesti- 
nal disorder. An enema was given and this brought 
away a strip of membrane six inches in length, stained 
with blood, with the result that the abdominal pain 
ceased. The intestinal trouble lasted about ten days, the 
temperature reaching 103' and 104° F. My theory is 
that there was a submucous extravasation of blood in the 
colon, analogous to the ecchymoses in the skin, and that 
this had caused the membrane to be exfoliated. The 
scurvy symptoms disappeared rapidly under the adminis- 
tration of orange-juice and the child is now well. 

DERMOID CYST REMOVED FROM A YOUNG CHILD. 

Dr. John F. Erdmann: I recently saw a child, one 
year and one month old, who had a small tumor above 
the left external angle of the frontal bone, directly over 
the outer edge of the orbit. It was the si7.e of a filbert, 
and was movable only in a transverse direction, being 
evidently partly bound down by adhesions, etc. A tenta- 
tive diagnosis of dermoid cyst was made. The tumor, 
subperiosteal in position, was removed and proved to be a 
cyst filled with cheesy and fatty matter containing half a 
dozen hairs from one-half to three quarters of an inch 
long. 

Not long ago I was called to a see a young man, 
twenty-two years of age. who was suffering from appendic- 
ular colic, this being his fifth or sixth attack. All the 
evidences of acute appendicitis were present. The pecu- 
liar feature of the case was the fact that the pulse-rate 
was slow, only 55, in spite of a subnormal temperature, 
97° F. The former, however, was of good volume and 
the general facial expression was not that of shock. Pal- 
pation revealed an appendix about as long and as large 
as my middle finger. During the next twenty-four hours 
the pulse increased five or six beats per minute, and the 
temperature became normal. At the end of forty-eight 
hours the pulse was only 68, a condition of tachycardia 
with appendicitis. Symptoms having moderated opera- 
tion was advised at a later date. A w-eek later I opened 
the abdomen and found an appendix 3X inches in length 
with a stricture 2 inches from the tip, and a large mucus 
inclusion. The patient made a good recovery. 

Dr. C. a. Leale then read the paper of the evening, 
entitled 

SEROUS cerebral APOPLEXY. 

This he described as a condition characterized by the 
rapid effusion within the brain or its membranes of the 
serum from the blood circulating within the cranial cav- 
ity. It may also be associated with a rupture of a blood- 



vessel and extravasation of blood, in which case it be- 
comes one of serosanguinous apoplexy. 

When simple, idiopathic apoplexy occurs not a drop of 
blood escapes, only serum is found, and there are appar- 
ently no other pathological evidences present in the brain 
or the surroundings; or a general cerebral edema may be 
present, similar to the "wet brain" of the paretic, due to 
interstitial effusion of serum and atrophy of the brain to 
make place for the serum. A sudden increase of this 
effusion may be caused by cerebral congestion, intense 
mental strain, great emotion, rapid dilatation of the 
stomach, etc., and sudden unconsciousness, or profound 
coma may supervene. If the patient be promptly and 
properly treated, he may quickly recover, or he may 
gradually decline until death ensues. The first symp- 
toms usually noticed are, profound nausea accompanied 
by attempts at vomiting, when the contents of the stom- 
ach may be sucked into the larynx or trachea and cause 
suffocation. In serous cerebral apoplexy the patient falls 
suddenly, the face becomes pale and the hands cold and 
clammy ; or in exceptional cases of the cyanotic type, the 
face becomes red, and the blood-vessels turgid. In some 
cases the brain retains its power, but usually its function 
is impaired and unconsciousness follows. In others cases 
there may be such a degree of cerebral edema and localized 
intracranial pressure that hemiplegia or general paralysis 
follows. The great danger in serous cerebral apoplexy 
is that the feeble heart will cease to continue action. 
Therefore the head should be kept low, the body at rest, 
and moist heat should be applied to the brain. If nec- 
essary forcible respiration must be employed. With 
this treatment the patient will usually so far recover that 
in the course of an hour he can be moved to a place of 
comfort, if still kept continuously in a prone position. 

The author cited several cases of serous cerebral apo- 
plexy, and one in a man, sixty years of age, who was 
suddenly stricken with serosanguineous apoplexy while 
quietly reading. He immediately became unconscious 
and soon passed into a state of profound coma. The 
condition of the patient was alarming and did not differ 
much from that of a man suffering from simple serous 
cerebral apoplexy. The man died without recovering 
consciousness, and an autopsy showed a very minute 
rupture at the circle of Willis. The opening was so 
small that it seemed almost impossible that death could 
have been caused by the small amount of blood extrav- 
asated. But in addition, a large quantity of serum was 
found at the base of the brain, and to the presence of the 
latter was attributed the profound coma which preceded 
and was the direct cause of death. 

Cases of serous and sanguineous cerebral apoplexy are 
of frequent occurrence and are attributed by the author to 
heart and kidney diseases, to the conditions under which 
business men of the present generation live, and to the 
rush, worry, and mental strain to which they are sub- 
jected. He emphasized the importance of examination 
of the eyes, as premonitory symptoms of the conditions 
may there be indicated weeks before an attack occurs. 
These are shown by redness of the conjunctivse, involun- 
tary tears running down the cheeks, and increased intra- 



July 29. 1899J 



NORTHWESTERN MEDICAL AND SURGICAL SOCIETY. 



'55 



ocular pressure. He considers such an examination of 
greater importance than urinalysis. 

Dr. Edward S. Peck: In regard to the ocular and 
intra-ocular symptoms which have been emphasized by 
the author, there can be no doubt that these exist. I have 
made a few examinations of the fundus of the eyes in these 
cases and have found a circumscribed periopiic effusion 
nicely limited to the region about the optic nerve. The 
condition is not an optic neuritis or an inflammation of the 
retrobulbar portion of the optic nerve, but in appearance 
is more like a hyperplasia of the retina itself. Usually, 
vision is not at first interfered with. The condition, as a 
rule, is present in both eyes and ultimately ends in optic- 
nerve atrophy. Some years ago I saw a man who was 
suffering from Bright's disease. He was attended by a 
promment medical practitioner, who had not recognized 
the disease, and who treated him for nausea and acute 
dyspepsia. I examined his eyes and found this veiy 
marked infiltration about the optic nerve, together wiih 
the peculiar condition of the nerve stem and macula, and 
gave the opinion that the man had only a short time to 
live. In two weeks he was dead. In two other cases I 
was able to predict early death after making an examina- 
tion of the eyes and noting this condition. One of these 
cases was an acute Bright's disease, and the other a 
serous apoplexy. 

Dr. S. N. Leo : I have seen many cases of cerebral 
apoplexy in people of advanced life, and there is no doubt 
that the premonitory symptoms referred to in the paper 
are often overlooked. I recall having made an autopsy in 
a very interesting case at the Colored Home some years 
ago. Two of the inmates had had an altercation and it 
was alleged that the dead man had been violently struck 
on the head by his comrade. I found a magnificently 
developed man, fifty nine or sixty years of age, but there 
was no mark or abrasion on his head or anywhere else on 
the body. As it was said that the man had bled from the 
ears I thought there might possibly be a fracture at the 
base of the skull. I made an incision well down below the 
occipital protuberance; the skull was exceedingly thick. 
After I lifted the pia mater and reached the arachnoid I 
noticed quite a large blood-clot under the pons, and an- 
other under the optic tract. Both were quite hard, show- 
ing that they had been formed some time. In ad- 
dition I observed an immense effusion in each ventricle. 
There was no sign of a fracture. It was further found 
that the man had advanced Bright's disease. The only 
conclusion which could be reached was that the man had 
died of an attack of apoplexy, such as has been so graph- 
ically described by Dr. Leale. I am of the opinion that 
the condition is largely superinduced by advanced disease 
of the kidney and by senile degeneration. I do not think, 
however, that the short-necked man is especially apt to 
have apoplectic seizures. 

Dr. Robert Newman: We have all seen the cases 
described by the author. The serous form of the disease 
is not so dangerous as the sanguineous because in the 
former there is no blood-clot to be absorbed. Many of 
the patients recover without treatment. I do not attach 
much importance to the premonitory symptoms for the 



reason that the attacks occur suddenly and unexpectedly, 
as a rule. In regard to the treatment of sanguineous apo- 
plexy, it is doubtful if much can be done. Rest and ef- 
forts of Nature will do most. However, I would like to 
ask the author whether he thinks that the iodid of potas- 
sium has a good effect in promoting absorption. In these 
cases the prognosis largely depends upon the degree of 
paralysis which usually exists to a greater or less extent. 
Dr. J. Blake White: In my experience it generally 
occurs that the serous form of apoplexy manifests itself 
more slowly than the sanguineous variety. The brain is 
tolerant of a slight degree of effusion, and the symptoms 
become alarming or fatal in proportion to the amount of 
effusion and its interference with function. I agree with 
Dr. Leo that short-necked individuals are not especially 
prone to this type of apoplexy but rather to the sanguine- 
ous or mixed variety. It is usually seen in persons 
broken down by chronic disease and in a cachectic con- 
dition occurring as a secondary affection. An ophthal- 
mological examination I can understand would assist very 
much in making an early diagnosis in these cases, and I 
am in accord with the views of the author that good results 
might follow if this precaution were taken. 

Dr. Robert H. Greene : I would like to say a word 
as to the prevention of most forms of apoplexy. It 
seems to me that heredity plays a strong part in the caus- 
ation of this condTtion, for in most cases the parents of 
the patient have suffered from atheromatous changes in 
the blood-vessels at an early age. These changes often 
take place at an earlier age than is required by the laws 
of Nature for one reason, because individuals are so apt 
while perhaps exercising their brains to e.xercise their 
bodies too little. If persons who are predisposed by 
heredity to this condition would e.xercise every da) meth- 
odically to the point of perspiration, their arteries would 
not break down as early. It is an established fact, de- 
termined by microscopical examination, that these de- 
generative changes begin in the muscular coat of the 
blood-vessel. 

Dr. S. H. Dessau; In regard to the differential diag- 
nosis of serous and sanguineous apoplexy, I would like to 
ask the author if hemiplegia is ever present in the former 
condition, or whether it is pathognomonic of the more se- 
vere form of apoplexy only. As the treatment in each is 
different, it is rather important that the two conditions 
be differentiated. 

Dr. J. H. Fruitnight: The term serous cerebral 
apoplexy is seldom used nowadays and modern writers 
have omitted it from their books. In sanguineous apo- 
plexy a change has previously taken place in the arteries, 
usually as the result of age, but not always. ".A. man 
IS as old as his arteries" is a trite saying for even in young 
men we see changts in the arteries as a result of syphi- 
litic degeneration, the well-known syphilitic endarteritis 
which often terminates in cerebral apoplexy. It seems * 
to me that serous apoplexy may be considered rather as 
the result of a toxemia and occurring most frequently as 
a concomitant of the so-called uremia of chronic nephritis. 
Dr. a. M. Jacobus: I desire to ask the author 
whether there are any records of autopsies made in cases 



156 



THE NEW YORK ACADEMY OF MEDICINE. 



[Medical News 



of serous cerebral apoplexy, and, if so, whether or not 
evidences of cerebral hemorrhage, embolism, or throm- 
bosis were found. I would also like to know what are 
the differential points in diagnosis between the so-called 
serous cerebral apoplexy and the other forms. 

The President: The paper contains many interest- 
ing points. I agree with Dr. Greene in what he has 
said about heredity being a causative factor. I was 
especially impressed by the truth of this some five or six 
years ago when I saw in consultation a case of this kind. 
The patient was a middle-aged man, and upon inquiring 
into the family history I learned that live of his brothers 
had died suddenly at or about the age of forty-eight. I 
predicted that he would not live more than twenty- four 
hours, and such was the case. 

I would like to hear the author say something about 
hemiplegia in these cases, and also in regard to the use 
of iodid of potassium to favor absorption, as suggested 
by Dr. Newman. 

Dr. Leale, in closing: In regard to treatment, I find 
that no remedy acts so well in relieving this condition as 
elaterium. It has a marked hydragogue effect, and 
causes a rapid pouring out of serum into the intestinal 
tract, and thus relieves the congestion in the brain. 
Rapid resorption of the serum then follows from all the 
cavities in which the serum lies. I have known two or 
three gallons of fluid to pass from the gastro-intestinal 
tract. Sometimes elaterium causes vomiting of fluid in 
consistency very much like the rice-water discharge of 
Asiatic cholera. The iodid of potassium, or the iodid of 
sodium, which is better borne, may be administered at a 
later period to complete absorption. Pilocarpin, which 
will produce profuse sweating within eight minutes 
is sometimes beneficial, but the objection to its use in 
serocerebral apoplexy is that it depresses the heart. It 
should never be employed if there is much intracranial 
blood-pressure with atheroma. The ali important pneu- 
mogastric nerve must always be considered and the 
teachings of physiology remembered. 

Hemiplegia, as a rule, does not occur in serous cere- 
bral apoplexy, for the reason that in this condition there 
is an equalized pressure upon the brain and not a local- 
ized pressure at any one point, as is the case in cerebral 
hemorrhage. But there may be a modified form of 
general paralysis, which generally passes off within 
twenty-four or thirty-six hours after the patient has been 
stricken. 

I have known a man stricken with serous cerebral 
apoplexy to remain unconscious for hours, yet be appar- 
ently well within a week. 

The term serous cerebral apoplexy is an old one and 
recent writers continue its use. 

We live in a time which produces men who die sud- 
denly. The Nevk- York business man lives under a 
tremendous pressure. Merchants, lawyers, clergymen, 
and doctors are all struggling for an existence and 
eminence. The pressure of life is so intense and the 
mental exertion is so great that it is easy for me to un- 
derstand why we see so many cases of serous cerebral 
apoplexy and sudden death. 



THE NEW YORK ACAD EMY OF MEDICINE. 

Stated Meeting-, Held Thursday, May l8, iSgQ. 
The President, Dr. Willi.\m H. Thomson, in the 
Chair. 

The first paper of the evening, on 

recent methods of local anesthesia for minor 

AND MAJOR SURGICAL operations, 

was read by Dr. Alexander B. Johnson. He said 
that the main advantage of local over general anesthesia 
is that it involves less risk. If local anesthesia could 
always be made absolutely painless this would be true. 
The shock and worry of operation during consciousness, 
however, and the pain it gives during and after operation 
are serious objections in many cases. 

In acute inflammatory cases the application of local 
anesthesia means a good deal of pain and there is a dull 
ache afterward that seriously disturbs the patient. In 
addition the infiltration of the tissues by the anesthetic 
may interfere with primary union. At times the dissec- 
tion of the tissues during the operation must unexpectedly 
be carried deeper than was anticipated, good anesthesia is 
hard to secure in the depths of the wound, the surgeon is 
disturbed, and his technic and the completeness of the 
operation is apt to suffer. 

At times, moreover, patients have an idiosyncrasy for 
cocain and excitement develops even after the employment 
of but small amounts. It may develop without warning, 
and this point must be carefully borne in mind by the 
surgeon. When marked idiosyncrasy exists, even small 
operations cannot be performed with local anesthesia, but 
even in milder forms the field of application for local an- 
esthetics is very limited. It was thought that most of 
the pneumonia that developed after operation would dis- 
appear on the use of local instead of general anesthesia, 
with its consequent irritation of the pulmonary mucous 
membrane. This, however, has not proved to be the 
case. Though more limited in application than was hoped 
at first it would be, local anesthesia is of distinct service. 
It may be employed with advantage in the surgery of the 
skin, the hand, the foot, the mucous membrane, the eye, 
for such operations as the wiring of the patella, the tap- 
ping of the knee-joint, urethrotomy, the resection of a rib, 
and the like. In major operations it is apt to impair 
operative technic and unless there is some special reason 
it should not be employed. In gastrostomy and in the oper- 
ation for cancer of the esophagus, when it is necessary to 
ovoid vomiting afterward, local anesthesia may be properly 
adopted. The speaker had seen cruel operations per- 
formed under local anesthesia, but it requires the utmost 
coolness on the part of the operator, and a certain hard- 
ness of feeling not often possessed by the surgeon. 

As to the means for local anesthesia ethyl chlorid 
serves a good purpose in superficial work, for skin in- 
cisions, or for needle insertions. The two great local 
anesthetics for introduction under the skin are cocain and 
eucain. The latter is growing in favor. For mucous 
membranes, as in the mouth, it is better to paint the site 
of operation with a strong solution, using a camel's-hair 
brush, rather than to spray the whole cavity. Symptoms 



July 29, 1899] 



THE NEW YORK ACADEMY OF MEDICINE. 



157 



of intoxication often develop suddenly and without warn- 
ing and are to be guarded against. In the urethra, local 
anesthesia may be secured by irrigation, the urethra 
being filled with a 5 -per- cent, solution, which is allowed 
to remain for one minute. It is claimed that half an 
ounce of a j-per-cent. solution will produce satisfactory 
anesthesia of the bladder, but the speaker said he had had 
no experience with this procedure. In the urethra special 
care is needed to guard against intoxication. Around the 
face sudden symptoms of intoxication sometimes develop. 
He had once seen 5 minims of a 4-per-cent. solution in- 
troduced into the supra-orbital region for neuralgia pro- 
duce alarming symptoms. In another case 6 minims of 
a like solution had a similar effect. 

In acute inflammation the pain is lessened by injecting 
the anesthetic around the inflamed area. In operations 
upon the hands and feet a rubber ligature should be ap- 
plied at the wrist or ankle or on the fingers or toes. The 
free bleeding afterward removes the cocain and much 
more of it can be used. It must be remembered, how- 
ever, that the application of a ligature is painful and 
gives rise to bitter complaints afterward. Injections 
made over the course of a nerve, as at the side of the 
finger, make the area of its distribution anesthetic. 

Schleich of Berlin adds the well-known anesthetic effect 
of tension to that of the drugs employed. His solution 
contains a minimal quantity of cocain and a certain 
amount of morphin, besides common salt. The morphin, 
however, is of no advantage as it has no local anesthetic 
effect. There are certain objections to Schleich's method, 
as the number of needle punctures necessary are an- 
noying to the patient and bothersome to the surgeon. 
The forcing in of fluid into an inflamed area may lead 
to the spread of infection and the tension on the tissues 
conceals anatomical details. 

Eucain solutions have the advantage over cocain solu- 
tions that they may be boiled. Cocain breaks up if 
heated to the boiling-point. There are some other sub- 
stances that have been used and recommended but clini- 
cal experience with them is not extensive enough to jus- 
tify a definite conclusion as yet as to their efficiency and 
value. Among them the most prominent a: e eucain "a", 
certain derivatives of guaiac and orthoform. None of 
them is capable of replacing cocain or eucain. 

In the discussion which followed Dr. Howard Lili- 
ENTH.\L said that two years ago he would have agreed 
with the essayist as to the very limited field there is for 
the use of local anesthesia. Now, however, he felt differ- 
ently. He learned to distrust cocain but now trusts eu- 
cain. As for pain with local anesthesia, patients often 
fear that they are about to be hurt and complain very much. 
The best proof, however, that they do not suffer actual 
pain is that they do not move. Cocain is especially dan- 
gerous because it depresses the heart. He had seen 4 
minims of a 5-per-cent. solution injected for the removal 
of a wart produce serious symptoms. Eucain, on the 
contrary, is a heart stimulant. Five grains may be used 
in the case of a feeble subject and as high as 10 grains 
has frequently been used without evil result. Eucain 
causes an unpleasant, painful feeling afterward. This 



may be relieved by packing the wound with orthoform 
gauze. That operations under eucain are painless, the 
fact that physicians have come back to have boils opened 
under it seems sufficient proof. A method not sufficiently 
employed by surgeons, though well known to dentists, is 
the cataphoresis of cocain. He had had sensitive dentine 
removed in this way absolutely without pain. 

Eucain should not be employed with a constrictor as it 
is liable to cause necrosis. For even serious operations 
eucain local anesthesia suffices very well. In three 
cholecystomies no pain was felt e.xcept that occasioned by 
pulling on the gall-bladder in bringing it up to attach to 
the skin incision. In operations for stranulated hernia 
the drug does very good service and he had used it very 
satisfactorily in operations for the radical cure of hernia. 

A hypodermic injection of morphin, X to '/< of a grain 
according to the patient's condition, relieves the mental 
strain and should be given a few minutes before the 
operation. If in the course of the dissection a nerve is 
met with a tiny drop of the solution should be injected 
directly into it. There need be no hesitation to give 
chloroform if it should be considered advisable after hav- 
ing tried eucain as the drug is stimulant not depressant. 

Dr. Bates said that cocain does not always produce 
local anesthesia satisfactorily for eye work. In operations 
on the muscles especially, pain is often complained of. 
When anesthesia is good a blanched appearance fol- 
lows the use of cocain. In certain patients hyper- 
emia of the parts developed and in these pain would 
always be complained of. In most of these cases the 
use of extract of suprarenal capsule used in conjunction 
with the cocain would produce the desired capillary 
closure with blanched appearance and anesthesia. The 
mental condition is important, however, and in excitable, 
neurotic patients, even with extract of suprarenals one is 
not always sure to obtain good local anesthesia. 

Dr. Johnsox said that he is not a pessimist as to 
local anesthesia. He uses it every day in dispensary and 
office practice. There is a good deal of pain associated 
with the use of local anesthesia and especially after the 
operation is over. As to neglecting a patient's complaints 
there are surgeons who can and still do justice to their 
work, but he cannot, and a squirming, complaining, pa- 
tient makes him hurried and not as e.xact and careful as 
he would otherwise be. 

The second paper, entitled 

FURTHER EXPERIMENTAL RESEARCHES ON THE EF- 
FECTS OF DIFFERENT ANESTHETICS UPON THE 
KIDNEYS, 

was read by Dr. Robert Cole.man Ke.mp. It con- 
tained the report of a series of exact observations upon 
the kidneys of animals in which an oncometer had been 
used to determine the varying size of the kidney and the 
amount of blood going to it at any time, while section of 
the ureter showed the amount of urine being e.\creted. 
Ether gave a characteristic oncometric curve with a per- 
sistent fall in blood pressure in the kidney and diminu- 
tion of the amount of urine passed. This was markedly 
different from the effect of any other anesthetic and even 
in anesthetic mixtures the presence of ether could be de- 



158 



THE NEW YORK ACADEMY OF MEDICINE. 



[Medical Ntws 



tected by its effect on the oncometric curve. As the 
ether was pushed urine became less and less in amount and 
more and more albuminous, and finally suppression of 
ur'ne resulted. 

Chloroform depressed the heart and consequently the 
kidney circulation, but albumin did not occur so abun- 
dantly and the decrease in urine was only proportionate 
to the decrease in general blood pressure. There was no 
specific effect of the chloroform upon the kidney as was 
the case with ether and urinary suppression did not occur. 

The A.C.E. mixture, in the proportion of i, 2, and 3 
by volume of alcohol, chloroform, and ether, acted differ- 
ently according to circumstances. If air were freely ad- 
mitted then the ether seemed to be without effect, and 
only the same effect as that produced by chloroform was 
noted. Without free admixture with air the ether kidney 
developed. 

Schleich's anesthetic mixture was found to be espe- 
cially severe on the kidneys, an emphasized ether kidney 
resulting very soon, with suppression of urine. No vari- 
ation of this result was noted when curara was adminis- 
tered. Nitrous oxid had the least direct influence. The 
circulation was slowed but immediately restored on with- 
drawing the gas. No specific effect was observed on the 
kidneys, and the effect noted was evanescent with rapid 
return to normal. 

Anesthol, Dr. Willy Meyer's proposed variant of 
Schleich's anesthetic mixture, is especially dangerous. 
Bloody urine occurred and complete suppression of 
urine set in very soon after the beginning of the 
anesthesia. The blood-clots could be traced up into the 
pelvis of the kidney so that the irritation was of the se- 
creting substance of the kidney. 

His conclusions were as follows : As far as their effect 
upon the kidneys are concerned Schleich's anesthetic mix- 
tures and anesthol are most dangerous, ether comes next, 
producing aspecificeffect on the kidneys, chloroform is less 
hard on the kidneys, and nitrous oxid affects them least. 
Some of these conclusions have been confirmed by clinical 
experience. After an anesthetic more than half the pa- 
tients have albuminuria when there was none before. 
Lawson Tait has pointed out that with chloroform the 
danger from the anesthetic was inmediate but with 
ether it was subsequent in the danger from pneumonia 
and uremia. 

The third paper, entitled 

TECHNIC OF ADMI.\1STRATI0N OF ANESTHETICS TO 
PATIENTS SUFFERING FROM KIDNEY TROUBLES, 

was read by Dr. Thomas L. Bennett. He does not 
consider a passing albuminuria even with a few hyalin 
casts as especially significant. They are not always due 
to the anesthetic but may be found also after operations 
where no anesthetic was employed. Exposure of the pa- 
tient during an operation seems to have this irritant ef- 
fect upon the kidneys and great care should be exercised 
i . keeping the patient covered especially when a kidney 
lesion exists. Then the patient should be transferred as 
soon as possible after the operation to a heated bed in or- 
der to arouse the skin to action. Operations on thegenito 
urinary tract seem to affect the kidneys reflexly and re- 



quire special precautions as to anesthetics and care for the 
warmth of the patient. 

In the order of their influence on the kidneys anesthet- 
ics may be arranged about as follows, beginning with 
the least harmful : (i) Local anesthesia. (2) Nitrous oxid 
with oxygen. (3) Nitrous oxid AMth air. (4) Chloroform. 
(5) Ether. Of any of the general anesthetics in a 
nephritic patient the smallest quantity possible should be 
used. Only analgesia, not complete anesthesia, should 
be sought. The conjunctival reflex should not be abol- 
ished, pupillary activity should remain, and other reflexes, 
and even soon slight pain, may be allowed to be present. 

Nitrous oxid is the least harmful but the state of as- 
phyxia it produces causes a passive congestion. If air is 
mixed with it the asphyxia is less, but the anesthesia is 
not so good. When mixed with oxygen, as Hewitt has 
suggested, it is least harmful. A special bag, with a 
diaphragm and a mixer for the two gases, is employed 
and the effect is very different to that seen when ordi- 
nary nitrous oxid is employed. It must be confessed, 
however, that certain subjects fail to be brought under the 
influence of the anesthetic sufficiently to permit of sur- 
gical operations. In some cases, too, vomiting occurs after 
nitrous oxid, and the after suffering is often great be- 
cause of the prompt revival from the anesthesia. 

Dr. Melzer, in the discussion, said that he considers 
the action of ether upon the kidney scarcely as a 
specific one. Caffein has just the opposite action 
upon the circulation to that ot ether. There is first a fall 
of blood pressure and then a rise, so that it becomes an 
interesting question as to whether caffein would compen- 
sate for ether. In case of suppression of urine, he has 
found salicylate of soda effective in restoring urinary 
secretion. The double salicylate of caffein and soda would 
seem to be especially indicated. 

Dr. Abbe said that despite the experimental results 
obtained he would trust to ether as an anesthetic. In a 
number of cases examined at St. Luke's Hospital albu- 
min and casts had been found in the urine after ether an- 
esthesia, but they were hyalin casts and disappeared after 
a day and practically no significance should be attributed 
to them. Even repeated administration of ether does 
not produce nephritis, and no lasting damage seems to be 
done to the healthy kidney. He also has seen good from 
the use of salicylate of soda in urinary suppression. In 
a case of pyuria he saw excellent results follow its ad- 
ministration. While in certain cases with only diminished 
urinary secretion not much effect seemed to follow its use 
he thinks it well worth further careful clinical observa- 
tion. 

It would be unfortunate if a diminished confidence in 
ether should follow the observations made in these physi- 
ological studies lor ether is our most trustworthy anes- 
thetic. The exposure of the patient during operation is 
important in its influence on the kidneys, but not the an- 
esthetic ordinarily. 

Dr. J. E. Kelly said that mixtures of anesthetics 
seem to combine all the disadvantages of their ingredi- 
ents. Some ol the more recently suggested mixtures 
would seem theoretically at least in this regard to be per- 



July 29, 1899J 



REVIEWS. 



159 



feet death-dealers. As for himself he prefers chloroform 
as an anesthetic. He has seen two deaths from chloro- 
form anesthesia both of which he considers could have 
been justly attributed to careless anesthetists. He has 
seen five or si.x deaths in ether anesthesia, and only once 
was the anesthetist at fault. 

Dr. Kemp, in closing the discussion, said that an 
important element in the effect of an anesthetic upon the 
kidneys is the susceptibility of the patient to irritants — 
his personal equation. For this it is advisable to know 
some details of his previous life and his tendency to re- 
act to exposure and the like. 



REVIEWS. 



The Serum Diagnosis of Disease. By Richard 
C. Cabot, M.D. Physician to Out-Patients, Massa- 
chusetts General Hospital, Boston. New York : Wm. 
Wood & Co., 1899. 

This volume adds little that is new to our knowledge 
of serum diagnosis : nor can it be regarded as a very 
practical laboratory guide. The author plainly disavows 
any such claims for his work. He states in his preface : 
"This book is nothing but a compilation. Its aim is to 
bring together in convenient form the results of the im- 
mense amount of work which has been done in 
serum diagnosis since 1896." With this sole purpose in 
view the author has presented in a clear and condensed 
form the results of the work of himself and others in the 
experimental and clinical study of serum reactions in 
typhoid fever, cholera, leprosy, tuberculosis, etc., these 
results being conveniently classified, compared and re- 
viewed. The review is not very critical, however. The 
greater part of the book is devoted, as might be expected, 
to the Widal reaction in typhoid fever. 

Both as a condensation of the literature of the subject 
and as a bibliographical reference, the work is of distinct 
value. It is well printed and freely illustrated. 

Progressive Medicine. A Quarterly Digest of Ad- 
vances, Discoveries, and Improvements in the Medical 
and Surgical Sciences. Edited by HobartA. Hare, 
M.D. Vol. II. June, 1899. Philadelphia and New 
York : Lea Brothers & Co. 

The second number of the new quarterly shows that 
the high standard already established and so well 
justified by the contents of the first volume is maintained 
and further substantiated. Dr. Coley presents an excel- 
lent up-to-date review, especially of the three subjects 
of greatest practical interest in abdominal surgery just at 
pre.'^ent : the surgery of the gall-bladder, of radical opera- 
tions for hernia, and for appendiciiis. In the surgery of 
the biliary tracts the recent work of Rehr in Ger- 
many and Mayo Robson in England has beeii most 
encouraging. It is evident that a great development in 
biliary surgery is about to take place and that active in- 
terference early in the case will replace the expectant 
methods that have been adopted up to this time. 

In the review ot the rcccni work on the radical cure of 
heinia Kocher's methods and rcbulis especially are de- 



tailed and commented on. In the last five years none of 
his patients have died and in no case in which Kocher 
himself has operated in recent years has there been a 
relapse. 

The review of the literature of appendicitis is very in- 
teresting especially because it brings out the fact that the 
subject is now as much discussed abroad as it has been 
here in America for the last few years. Czerny's view that 
the first attack of appendicitis belongs to the physician is 
the expression of an ultra conservative, as practically all 
are agreed that appendicitis is now from the very begin- 
ning a surgical affection. 

Dr. Clark in "Gynecology" presents a very interesting 
review of the recent experimental work done on the trans- 
plantation of the ovaries. There would seem to be pos- 
sibilities ahead in this subject that ma/ lead to important 
and very practical developments. With regard to that 
very interesting subject, the occurrence and prevention of 
ventral hernia after operation, some very striking facts are 
brought out. For instance, it is clear from Abel's inves- 
tigation of the case of Professor Zweifel, the head of the 
the Gynecological Clinic at Leipzig, that a number of 
prejudices are unsubstantiated by actual experience. 
Abel succeeded, with what painstaking patience may be 
well imagined, in getting the after histories of all but five 
of nearly 700 patients. From his statistics it would ap- 
pear that the wearing of a bandage has absolutely noth- 
ing to do with the prevention of hernia, and the time of 
resumption of active work by the patient stands in no 
causal relation to the production of the lesion. There is 
abstract of the discussion between Behrens of Berlin an 
and Professor Neisser of Breslau on the treatment of gonor- 
rhea in women in which Neisser 's plea for active germicidal 
treatment rather than that by simple astringents is com- 
mended and his recent declaration of faiih in ichihyol for 
this purpose commented on favorably. 

We are tempted to say more about the good things in 
this number and cannot close our review of it without at 
least a reference to Dr. Stengel's very interesting abstract 
of recent work on the relations between diabetes and gly- 
cosuria and Dr. Jackson's excellent review of the recent 
literature of the toxic amblyopias. 

Urinary Analysis and Diagnosis by Microscopical 
and Chemical Examination. By Louis Heitzmann, 
M.D. With 108 Original Illustrations. New York : 
William Wood & Co., 1899. 

The meritorious feature of this new manual of urinary 
analysis is us illastrations, all o( them original. The 
plates showing the different forms of celte that occur in 
urine, with their probable origin, are especially interest- 
ing. The clusters of fattily degenerated epithelial cells, 
with their abundant content of bacilli and cocci, which 
constitute smegma, and which occur so often in the urine 
of females, have not belore been so fully described or so 
characterisiencally illustrated as they deserve. There 
is, perhaps, a tendency noticeable in the book to claim 
too much for the possibilities ol recognizing microscop- 
ically the site of origin ot the various forms ot epithelial 
cells, but the fault is in the proper direction, for, as a 



i6o 



THERAPEUTIC HINTS. 



[Medical News 



rule, diagnosticians do not make sufficient use of the his- 
tological indications furnished them by the various cells 
that occur in urinary sediment. In this respect the book 
is a distinct advance on handbooks of urinary analysis 
generally. The characteristic microscopic picture of the 
urinary sediments of such conditions as acute and chronic 
prostatitis, of spermatocystitis or seminal vesiculitis, and of 
chronic catarrhal vaginitis are interesting and suggestive, 
even though one may not be prepared to go as far as the 
author in enthusiastic claims for the diagnostic usefulness 
of the microscope m these conditions. On the whole, 
the book is one of the best of its kind and is thoroughly 
up to date. 

Materia Medica and Therapeutics. An intro- 
duction to the Rational Treatment of Disease, for the 
Use of Students and Practitioners of Medicine. By J. 
Mitchell Bruce, M.D., F.R.C.P., etc.. Physi- 
cian and Lecturer on Medicine at Charing Cross Hos- 
pital, London. Sixth Edition, revised and enlarged. 
Philadelphia and New York: Lea Brothers & Co., 
1899. 

This work appears in the same compact form which 
(together with its scientific value), made it in the first 
edition so popular among American, as well as among 
English, students. Changes have been made in the text 
to adapt it to the new British pharmacopoeia and to make 
it representative of recent advances in our materia medica. 
There is no reference, however, to those of our newer 
drugs which, though unofficinal, are well deserving of 
mention in a book of this character. 

The discussion of the various remedies is admirably 
divided; e. g., in the separate treatment of "immediate 
local actions," "actions on the blood and specific actions," 
"remote local actions," etc. VVe cannot bestow as much 
praise on the general grouping of the remedies. VVe be- 
lieve that a change from the chemical and botanical class- 
ification to the more rational arrangement according to 
physiological effects would have marked a distinct im- 
provement in the new edition over the first one. The 
adopted subdivision robs the work of much of its value 
as a reference for the physician, and fails to present the 
pharmacopctia in an impressive therapeutic review to the 
overta.xed memory of the student. 

The te.xt, however, is interesting, so far as that of a 
condensed hand-book on materia medica can be. Un- 
essential details are omitted and salient facts are tersely 
and unequivocally presented. One of the most attractive 
features of the work is the interesting and scholarly divi- 
sion devoted to general (and we might add special) 
therapeutics. 

Electrohemostasis in Operative Surgery. By 
Alexander J. C. Skene, M.D., LLD., Professor 
of Gynecology in the Long Island College Hospital of 
Brcoklyn, etc. New York: D. Appleton & Co., 1899. 

The author of this book has been an advocate of electric 
hemostasis in surgical operations since he first learned its 
usefulness. In the present work he presents an elaborate 
review of the subject including a description of the essential 



instrument and macroscopic and microscopic examinations 
of tissues burned with the electric cautery. It is this 
chapter which will most interest surgeons since it gives 
the ration d'etre of this method of controlling bleeding 
in surgery. Dr. Skene shows that by means of the 
cautery the lumen of an artery becomes entirely ob- 
literated ; that after two hundred trials no secondary 
hemorrhage ensued ; that an artery a quarter of an inch 
in thickness was reduced to about one- twelfth of an inch 
in thickness and that the tissues were rendered amorphous 
by the heat and pressure. The treatment of friable tissues 
which cannot be ligated, and the closure of canals lined 
with mucous membrane, and the sterilization of the parts 
as well, can be accomplished better by this means than 
any other. The author finds that pain is dimin- 
ished by this method of hemostasis on account of 
the devitalization of the nerves severed. The remainder 
of the book is taken up with chapters on the use of the 
electric cautery for hemostatic purposes in the various 
branches of surgery, and two chapters on aseptic and 
antiseptic surgery. As a pioneer in this field of surgi- 
cal technic the book is interesting and deserves careful 
reading by every man engaged in surgical work. 



THERAPEUTIC HINTS. 



The Addition of Chloroform to Alcoholic Solutions of 
Bromoform renders them miscible with water in any pro- 
portion, whereas the bromoform would otherwise be pre- 
cipitated by the water, For instance : 

^ Bromoformi .....///. xviii 
Chloroformi . . . . .in. xii 
Rum . . . . q. s. ad. I ii. 



gr. XV 
gr. iss 

3ii. 



Application to a Cancerous Cervix. 

IJ Orthoformi 
Ac. arseniosi 
Spiritus 
Aquas 

M. Sig. Saturate a tampon with this solution and apply 
to cervix. 

For Pertussis. — The following is the formula prescribed 
by MoRlTZ COHN of Hamburg from which he claims ex- 
cellent results: 

5 Bromoformi 

Absolute alcohol 

Pulv. acacia; 

Syr. aurantii 

Aq. dest. . . . q. s. 

Dissolve the bromoform in the alcohol, 
fully with the acacia and gradually add the syrup and 
water. Sig. One to two teaspoonfuls every two hours. 
Keep in a dark bottle and shake well before using. 

For Infectious Infantile Diarrhea. — 

R Laudanum of Sydenham . . . gtt. '/i 
Ac. hydrochlorici dil. .... gtt. ii 
Sugar water . . . . . 3 v. 

M. Sig. Give at one dose. Repeat several times a 
day if indicated. 



; 


m. iii-xii 
m. x-xl 




."ad. 


gr. Ixx.x- 

3SS 
liv. 


3v 


)hol, 


triturate care- 



THE MEDICAL NEWS 

A WEEKLY JOURNAL OF MEDICAL SCIENCE. 



Vol. LXXV. 



New York, Saturday, August 5, 1899. 



No. 6. 



ORIGINAL ARTICLES. 

THE OCULAR AND ORBITAL SYMPTOMSOF 
LESIONS OF THE FRONTAL SINUS.' 

By ROBERT SATTLER, M.D., 

OF CINCINNATI, OHIO. 

Suggestion's drawn from carefully conducted 
clinical studies, with the disclosures of surgical ex- 
perience, have led to and clearly defined a rational 
and eminently practical surgery for these obscure 
lesions of the sinuses of the frontal bone. The path- 
ologic processes which invade these pneumatic cav- 
ities are better understood than formerly. The 
acute ones disclose their nature with almost cer- 
tainty of diagnosis. Their clinical characteristics 
and the indications for surgical intervention can, 
in exceptional cases only, be misinterpreted. 
Chronic lesions are of far more frequent occurrence. 
Their course is marked, almost without exception, 
by interminable chronicity, with clinical attendants 
so meager or uncertain that error in diagnosis is fre- 
quent. The reasons for this are evident. Those 
which result from transplantation of pyogenic prod- 
ucts from the adjacent nasal cavity — which are 
again the most frequent — and those as well which 
are due to direct extension along the mucous lining 
or bony walls from intranasal disease along the con- 
necting channel or frontal canal, occur with espe- 
cial frequency among male adults. These air spaces 
have even during early adult life reached spacious 
dimensions and their bony encasement is fortified as 
age advances The low grade of inflammatory ac- 
tivity which commonly attends such processes and 
the compensatory hypertrophy or sclerosis of the 
walls which is thereby excited combine to decree 
for the incarceration of pyogenic matter, granula- 
tion tissue; inspissated pus, etc., an almost latent 
course with uncertain or absent clinical features. 

These are among the causes why recognition of 
chronic lesions is wellnigh impossible during the 
early stages or until more tangible evidence of per- 
foration of the outer wall with undermining of the 
periosteum and other symptoms point to their real 
nature, .^gain, in consequence of the constant 
choking with granulation tissue or other pathological 
products, the cavity is abnormally distended and 
immense rarefaction, with atrophy of the bony walls, 

' Read before the Ohio State Medical Society, at Springfield, | 
Ohio, May 12, 1899. 



as well as of the mucous lining, results, accom- 
panied by partial absorption or desiccation of their 
contents. This larger cavity, with thinner walls, is 
completely shut off from all communication with the 
nasal cavity through the infundibulum or fronto- 
nasal canal. Disturbance of its physiological pur- 
pose follows and occasions constant distress, with 
often, also, violent explosions of neuralgic pain 
over this locality. It may also happen that increase 
of thickness or hyperostosis of the external walls re- 
sults, especially as a final expression of a chronic, 
latent, lesion. Not infrequently is this attended by 
violent outbursts of neuralgic pain without local or 
inflammatory symptoms. In such cases, surgery, 
which may suggest itself and be practised as an em- 
pirical measure for diagnostic means, or in search of 
pus, even in the absence of any positive assurance of 
its presence, reveals only bone hypertrophy. Why 
this should cause, in some cases, violent suffering 
and in others none, is as unexplained as are the va- 
garies of other similar lesions of the temporal bone. 
We also meet with the same negative expression in 
other secondary lesions. The growth of osteophites 
or exostoses within the sinus with the latter enor- 
mously distended, affords only another illustration. 
With the exception of the increasing deformity, pain 
or other subjective discomfort remains absent. 

It has already been stated that it is during early 
and middle adult life that the original sinus lesion, or 
the final expression of such lesion, is met with. The 
discovery of the real character of such resulting or 
secondary lesion, however, is possible only after 
the surgical intervention which becomes expedient 
or necessary reveals it. 

This does not imply that lesions with a similar la- 
tent course are not met with also during the earlier 
years of life. Experience has taught me, especially 
my earlier observations, that the cases of so-called 
periorbitis and unquestionably also, a goodly share 
of the cases of caries of the margin of the orbit, in 
strumous or rachitic children, are really expressions 
of frontal sinus disease. The earlier stages of the 
lesion are latent, as in the older subjects, but owing 
to the thinness of the bony enclosures and the small 
size of the cavity perforation occurs more readily and 
almost as a necessary sequence. 

The temporal angle of the sinus is a not infre- 
quent location for perforation by the retained 
contents, and a trail of burrowing pus follows of nee- 



l62 



LESIONS OF THE FRONTAL SINUS. 



[Medical News 



•essity the contour of the orbital margin and its out- 
let or sinus eventually opens near the outer canthus. 
This remote location, so far removed from the ori- 
ginal starting point, is not at at once associated with 
a sinus lesion. It is a disclosure of surgery and a 
noteworthy triumph as well, which has proved the 
truth of this statement, and has enabled us to treat 
these obstinate cases with far greater satisfaction and 
the avoidance of unsightly deformity. 

Some fifteen years ago I began a systematic and 
careful study of all cases belonging to this category. 
The first attempts of exploratory surgery in chronic 
cases with latent course, in which a retention of pus 
or other inflammatory products was surmised, were 
made with old-fashioned drills and trephines. Brief 
mention of one of the first cases is made, because of 
its instructive lesson: 

A lad, aged twelve years, had suffered for years 
from frontal and general headache. For some time 
his parents had noticed an increasing prominence 
of the region over the frontal sinuses and inner, 
upper margin of the orbit. Nasopharyngeal catarrh 
was present but there were no unusual features. The 
customary local treatment had been tried ineffec- 
tually foralong time, without relief of the headache. 
There was no tenderness over the frontal sinus region 
nor redness or swelling of the soft parts. Unmis- 
takable bone enlargement, however, was present. 
Ocular symptoms there were none, except epiphora, 
which was neither persistent nor annoying. In 
spite of these negative symptoms the sinus was 
opened with a drill, which operation, owing to the 
thickness of the bone was both difficult and tedious. 
Extensive hyperostosis was found and the sinus was 
full of pus. Subsequently the other sinus was 
opened with similar disclosures. Recovery ensued, 
■with complete subsidence of pain. 

The point which this brief recital emphasizes is 
that exploratory surgery, aided and reinforced by 
modern surgical methods with the use of less cum- 
bersom^nsjruments, affords us an opportunity for 
the practice of rational and successful surgery. 

Taking up, briefly, the especial purpose of this 
paper, the ocular and orbital symptoms of the more 
uncommon chronic lesions, it must again be stated 
that, for an indefinite period, such lesions or their 
final expressions may run an entirely latent course 
both as far as local and constitutional disturbances 
are concerned. 

Orbital Symptoms. — Among the first tangible evi- 
dences are diffused and localized tenderness, without 
redness or swelling over the affected region. This 
is generally unilateral as it is rare to find both cavities 
affected at the same time. This gives way to trans- 
itory, painful swelling of the periosteum and bone. 



often with redness and swelling of the overlying 
soft parts. These symptoms come and go, lasting 
generally several days or weeks. Headache now 
may become general. At the same time there will 
be observed a characteristic indication, and this is a 
change of contour of the inner, upper, and in some 
cases, even of the inferior margin of the orbit. If 
the lesion is unilateral, and it generally is, the 
asymmetry of this important part of the face and the 
change of physiognomy which it entails, point with 
significance to an existing sinus lesion. If tender- 
ness on pressure or percussion is present, it is even 
more suggestive of this view. 

The most careful rhinoscopic examination fails to 
disclose more than a chronic catarrhal process which 
is known to have been present and to which, also, 
the symptoms due to the sinus complication are as- 
signed. In some cases even, the symptoms of an 
existing nasal lesion are in abeyance during the prog- 
ress of the sinus lesion. 

If the grade of inflammatory activity remains low, 
it may happen that a chronic empyema may undergo 
partial absorption or inspissation and terminate in a 
contraction of the cavity with increased thickening 
of the walls; in other words, hyperostosis results. 
It may also happen at this stage or with the presence 
of the symptoms referred to, that a spontaneous 
evacuation through the frontonasal canal into the 
nose, effects in some cases temporary arrest and 
in a lew, complete termination of the sinus lesion. 
In exceptional cases, among those first mentioned, 
in which hyperostosis of the walls takes place and 
recovery without external perforation results, there 
comes about as a remote sequence, neuralgic seizures' 
of extraordinary severity and duration. A more 
frequent result, however, is the yielding of the walls 
at one or another point. In children this is not in- 
frequently the temporal angle of the sinus, but with 
them and with adults it is more often the lateral 
or orbital wall at points near, above, or even below 
the inner canthus of the eye. 

The periorbita in this locality is firmly attached to 

1 This patient, a man aged thirty-six years, had suffered from 
what he and his physician supposed was intense paro.xysms of 
supra-orbital neuralgia of the right side. Years before he had 
contracted syphilis but no manifestations of late syphilis were ob- 
served. Nevertheless, he had received the most thorough anti- 
specific treatment for several years. The entire frontal region 
near the margin of the orbit, which was thickened, was the seat of 
an extensive and marked bone hypertrophy. This swelling was 
smooth except at the under surface, near the free margin of the 
orbit where irregularities were discovered. He suffered constantly 
from pain with exacerbations of more violent seizures at short in- 
tervals. Drooping of the upper lid but neither exophthalmos nor 
lateral displacement of the eyes was present. An exploratory 
operation discovered most extensive thickening of ilie bone which 
was hard and brittle and not vascular. Several fistulous openings 
in the bone, near the upper margin of the orbit, were discovered, 
but there was no pus or offensive discharge. The sinus was fully 
opened. The cavity was small and partially filled with caseated 
pus. The entire region was ablated, and recovery, though tedious, 
resulted with complete subsidence of the intense neuralgic seizures. 



Algi ST 5, 1899] 



LESIONS OF THE FRONTAL SINUS. 



163 



the bone and is furthermore reinforced by the orbital 
fasciae and medial ligament and this explains the 
resistance which is offered to the burrowing pus. 
For this reason the dissecting trail is often deflected 
and pushes its destructive work lower down while 
its most frequent outlet is under and at the outer or 
temporal border of the tear-sac. Not infrequently- 
several fistulous openings discharging the contents of 
the sinus frontalis appear along the orbital margin 
near the middle or even its outer division. 

They may also undermine the periosteum tear-sac, 
erode the os unguis and superior maxillary of this 
region and without external perforation discharge 
their contents into the nose. In particular do we 
observe this in broken-down syphilitic subjects. In 
such cases, both internal and external perforation 
is likely to take place. 

Ocular Symptoms. — The earliest ocular man- 
ifestations are observed on the part of the eyelids. 
A serous infiltration of the loose cellular fascis of 
the roof of the orbit dependent upon and associated 
with the transitory exacerbations of the insidious 
sinus lesion may interfere with the action of the 
levator muscle of the upper lid, and also with the 
superior rectus muscle. Drooping of the upper lid 
and slight restriction of motion upwards is often ob- 
served. Proptosis, due to the same cause, and 
lateral downward displacement of the globe may 
also be present, even at this early [)eriod. To these 
symptoms are added an edema of the inner third of 
the upper lid with dusky discoloration. I'his, in 
some cases, is so much like the inflammatory edema 
and tissue infiltration which attends a suppurating 
-chalazion that it is not int'requently mistaken for 
this. On the part of the conjunctiva, especially the 
retrotarsal and ocular divisions, engorgement of the 
venous channels and frequently chemosis are ob- 
served. This is not of inflammatory origin, but is 
due to obstruction of the outflow of the venous chan- 
nels. In some cases the upper fornix at this point 
.is evulsed. Pus-trails may cause this and discharge 
their contents into the conjunctival sac. 

The symptom of proptopsis is a variable one and is 
not in conspicuous evidence even in pronounced 
• cases of uncomplicated frontal sinus disease. In 
those cases in which a necrosing syphilitic lesion in- 
vades the ethmoidal cells and frontal sinus jointly, or 
all the pneumatic cavities are involved, this is al- 
most uniformly present. 

A feature of the exophthalmos accompanying 
sinus frontalis lesions deserves mention. In com- 
mon with similar processes of the ethmoidal cells it 
is subject to great variation. At times it is present 
and again it disappears entirely. Only in most ex- 
ceptional cases, in which perforation under the peri- 



orbita takes place behind the margo orbitalis and 
insertion of the orbital fascia and medial ligament, 
and the dissecting trails push backward toward the 
apex of the orbit, is dislocation of the eye a neces- 
sary effect and exophthalmos a conspicuous symp- 
tom. 

To this rather incomplete description of the clin- 
ical features a brief account of a typical case is 
added in order that it may supplement what may 
have been omitted: 

The patient, a lad aged twelve, had, for several 
months, complained of general headache, which did 
not yield to treatment, general and local, and faith- 
fully tried. His parents were healthy, the boy was 
well developed and free from any evidence which 
might suggest constitutional disease. Several weeks 
before he was brought to me he was taken to the 
family physician who attempted to open what he 
supposed to be an ordinary hordeolum near the in- 
ner border of the upper lid. When he first came to 
me the asymmetry between the frontal regions of the 
two sides vifas unmistakable. The entire inner half 
of the right upper lid was infiltrated and the skin 
dusky in color. The movements of the lid were re- 
stricted and the palpebral fissure distorted and con- 
tracted. The superficial veins of the conjunctiva 
were tortuous and prominent. Proptopsis, with slight 
lateral displacement was present, but neither diplo- 
pia nor restriction of ocular movements was noted. 
Functional examination of the eye was perfect and 
nothing noteworthy, on ophthalmoscopic e.xamina- 
tion, was observed. The entire inner and upper 
margin of the right orbit was tender on palpation, 
but redness was confined to the tissues of the lids. 
At the point under the tear sac which appeared 
more prominent as compared with the other ormore 
healthy side, tenderness on the slightest pressure 
was complained of. Over the sinus itself, however, 
it required a much firmer pressure to excite pain. 
Fever and lassitude, which had steadily increased, 
were constant. Surgical intervention was practised 
without delay. It brought unlooked for revelations. 
The sinus was uncommonly roomy considering the 
age of the patient, and was crowded with granula- 
tion tissue and pus. On the under orbital surface, 
bone perforation had occurred in several places. 
The pericranium was extensively elevated and a 
large trail was discovered, leading under the tear- 
sac and side of the nose, which corresponded to the 
point of greatest e.xternal tenderness. Recovery was 
tedious but unattended by complications. 

The surgical methods which enable us to explore 
the sinus frontalis from without for diagnosis and 
successful treatment are, at present, so satisfactory 
that few surgeons attempt drainage or exploration 



1 64 



TREATMENT OF HIP-DISEASE. 



[Medical News 



through the intranasal opening. I have long since 
abandoned this method as uncertain and unsatisfac- 
tory, and resort exclusively to the external one with 
chisel and mallet. Trephines and dental drills are 
preferred by some surgeons, but the simplicity and 
ease of manipulation of the method and instruments 
referred to justly entitle them, in my opinion, to 
the preference. 

SOME SALIENT POINTS IN THE TREAT- 
MENT OF HIP-DISEASE.' 

By B. E. Mckenzie, m.d., 

OF TORONTO, CANADA. 

Not only to the orthopedic surgeon but to the 
general practitioner and the laity is hip-disease a sub- 
ject of perennial interest. Though this affection 
has been presented again and -again in all its aspects, 
yet there maybe some advantage in setting forth the 
results of individual study. In doing so the indul- 
gence of the Association is craved if the writer should 
seem somewhat dogmatic in the assertion of his own 
opinions. Through a clear-cut statement of his own 
views his paper will the better elicit the valuable re- 
sults of the large experience of the members of this 
Association. 

The question may be regarded as settled that 
when an early diagnosis is made effective mechanical 
and constitutional treatment is always to be pre- 
ferred to operative measures. There are few who 
to day would adhere to the opinions advocated by 
Barker in the Hunterian Lectures of 1887. One is 
scarcely surprised that stimulated by some impor- 
tant advances of nearly twenty years ago surgeons 
went to extremes in operative work. The most im- 
portant of these advances were the practice of asep- 
ticism and the discovery of the bacillus tuberculosis. 
Strong claims were made in favor of early operation 
resulting in speedy cure. Everywhere we find sur- 
geons w-ho believed and who acted on the belief 
that as soon as a diagnosis was made excision of the 
joint should be performed, thereby removing the 
femoral head and all infected tissue, cutting short 
the course of the disease, forgetting for the moment 
that they were rarely able to eradicate all the in- 
fected tissues. It may candidly be said that all 
these fair promises held out by distinctively opera- 
tive treatment were not realized. 

Although these patients were sometimes sent 
home a month or less after the operation, with the 
wound healed, this seeming to be a most satisfactory 
and gratifying result calculated to beget a hope that 
by operative measures alone these subjects could be 
cured in a short time, yet further observation often 

' Read at the thirteenth annual meeting of the .-Kmerican Ortho- 
pedic Association, held at New York, May 31, and June i and 2, 
1899. 



showed a recurrence of the disease. Though the 
greatest precautions were taken, yet untoward re- 
sults, even death, sometimes followed as the direct 
consequence of the operation. Even in the cases 
in which the most favorable course possible was 
taken it was found that excision of the femoral 
head in itself was the cause of no slight disability, 
and in a considerable portion of the cases the focus 
of disease at the head was not the only one, and sub- 
sequently tuberculosis manifested itself elsewhere. 
There are serious hindrances to the successful ac- 
complishment of the complete eradication of the 
disease. One of the epiphyses, that most frequently 
invaded primarily, is so situated as to be entirely 
within the capsule. Its removal calls for an exci- 
sion, which in all cases greatly invalidates the joint 
function, permitting the limb to slide upward in its 
relation to the pelvis, thus becoming insecure for the 
purpose of weight bearing. If the primary focus be 
in the floor of the acetabulum, as it is in a consider- 
able proportion of cases, it cannot be reached without 
complete excision. On the other hand, if the 
primary focus be found at an early date at either of 
the trochanters or in the synovial membrane there 
is a better prospect of its removal without serious 
interference with the integrity of the joint. Such 
definiteness of diagnosis is seldom possible. An 
early diagnosis of the presence of disease can be 
made, but to determine the exact location of the 
primary focus is not possible. 

Even operators of the most extensive experience, 
such as Volkmann, and George A. Wright have said 
that "if the case be taken in time the best results 
are obtained by rest." Mikulicz regularly treats 
his patients with joint tuberculosis by iodoform in- 
jection without incision. Considering all the evi- 
dence and giving due weight to the facts of experi- 
ence, the writer is of the opinion that operative 
interference at the hip is teldoni justifiable before 
the breaking down of tissue may be diagnosed. 

The loss of the femoral head, whether through 
operation or the destructive process of disease, must 
be regarded as one of the most undesirable results. 
The shaft of the femur slides upward, and marked 
shortening occurs; but what is more serious,